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Diarrhoea and Vomiting Management Policy

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Diarrhoea and Vomiting Management Policy Powered By Docstoc
					PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL POLICIES: INFECTION CONTROL



TITLE                       POLICY FOR THE MANAGEMENT OF DIARRHOEA AND VOMITING
MANAGER /
COMMITTEE                   Infection Control Team
RESPONSIBLE
DATE ISSUED                 29.02.2008
VERSION                     2
REVIEW DATE                 December 2008
Equality Impact
Assessment has
                            Mary Pilgrim. Senior Nurse Infection Control
been applied to this
policy
AUTHOR                      Infection Control Team

RATIFIED BY                 Chair of the PROFESSIONAL ADVISORY COMMITTEE – 29.02.2008

AMENDMENTS RECORD
     DATE                            PAGE                      COMMENTS                APPROVED BY
                                                               Action Plan
        09/01/08                      15-19                   reviewed and               Mary Pilgrim
                                                                 updated



CONTENTS:
                                                                                                           Page
 1      INTRODUCTION                                                                                          2
 2      STATUS                                                                                                2
 3      PURPOSE                                                                                               2
 4      SCOPE/AUDIENCE                                                                                        2
 5      DEFINITIONS                                                                                           2
 6      PROCESS                                                                                               5
 7      DUTIES AND RESPONSIBILITIES                                                                          11
 8      TRAINING                                                                                             12
 9      ASSOCIATED DOCUMENTATION / REFERENCES                                                                12

APPENDICES:
Appendix 1: Clostridium difficile                                                                             13
Appendix 2: Stool/Vomit Chart                                                                                 14
Appendix 3: D & V Outbreak action plan                                                                        15
Appendix 4: Escalation Plan                                                                                   20
Source Isolation notice                                                                                       24
Protective Isolation notice                                                                                   25
Appendix 5: HPA Good Practice Guide                                                                           26
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1. INTRODUCTION / BACKGROUND
Outbreaks and/or incidents of diarrhoea and/or vomiting can be a significant cause of healthcare associated
infection resulting in additional morbidity and mortality as well as contributing to healthcare costs.
Appropriate management of the patient(s) presenting with symptoms of an infectious diarrhoea is paramount
to reducing the incidence of an outbreak while maintaining other clinical needs of the patient (s).

The two main causes of an outbreak of diarrhoea and/or vomiting in a Healthcare setting are either
Clostridium difficile and/or gastro-enteritis due to small round structured viruses.

2. STATUS
Clinical Policy

3. PURPOSE
This Policy defines the actions taken by this Trust to reduce the transmission of infection associated with
diarrhoea and vomiting by reducing the movement of the patient and contacts and preventing cross
infection within the healthcare environment. This Policy informs all healthcare staff of their individual
responsibilities to effectively manage diarrhoea and/or vomiting.

4. SCOPE/AUDIENCE
This Policy applies to all PHT staff health and non-healthcare including agency, bank and locum staff.

5. DEFINITIONS

Bed Management
Bed management must ensure patient safety while responding to operational demands. Pro -active
communication between Infection Control Team and Bed Management may be required to establish
Outbreak Contingency plan.

Bio-burden
Number of colonising or contaminating bacteria / viruses on any item including hands.

Clostridium difficile
Clostridium difficile is an anaerobic, gram positive spore forming bacillus. These spores are resistant to
exposure to air, drying, heat and survive in the environment. Following antibiotic therapy the intestinal flora
is altered which allows any C difficile bacteria to proliferate. The bacteria produce two toxins:
      Toxin A which irritates the colon and causes what is commonly known as antibiotic associated
         diarrhoea, which can lead to pseudo-membranous colitis (PMC)
      Toxin B that is predominately cytotoxic
The source may be the patient themselves (endogenous) if they are the carrier or it can be acquired from
the environment (exogenous). (Appendix 1).



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Cohort nursing:
A group of patients with a disease or infection who are separated from patients who do not harbour the
disease or infection and who are nursed in a geographically distinct area or with physical separation in the
same room. Isolation in separate rooms is preferable to cohort nursing. Ideally, the same nursing staff
should provide daily care for the same cohort for the duration of the isolation.




Decant Ward
An area set aside for the use and exclusion of a group of patients identified with similar signs and
symptoms of diarrhoea.

Diarrhoea
Frequent episodes of loose stools (Bristol Stool Chart) (Appendix 2).

Endemic disease:
The continued presence of a disease-causing organism with, or without infection, in a given hospital or in a
given group of patients in a hospital, or in a geographical area despite standard control procedures. (see
epidemic).

Environmental contamination: the area around the patient is contaminated e.g. with clostridium spores.

Epidemic:
The outbreak of or acquisition of a disease-causing organism spreading widely among people at the same
time in a hospital or community (e.g. in a residential facility) or in a geographical area with a frequency that is
clearly in excess of normal expectancy.

Exclusion rule
Strict adherence to 72 hour exclusion rule for patients and 48 hours for staff.

Fomites,:
Inanimate objects that when contaminated with a viable pathogen can transfer the pathogen to a host.
Examples include door handles, telephones, computer keyboards, or any shared item.

Gut flora: the human gut contains a number of bacteria/flora.

HAI: hospital-acquired infection, or healthcare-associated infection;
Also known as a nosocomial infection. This includes infection acquired in a variety of institutions and not just
acute hospitals.




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Hand Hygiene
Hand hygiene is a term that incorporates the decontamination of the hands by methods includ ing routine
hand washing and the use of alcohol hand rubs and gels (Hand Hygiene Task Force 2002). The importance
of hand hygiene in the prevention of cross-infection was clearly demonstrated in the Nineteenth Century
(Ayliffe & English 2003). Since that time the hands of staff have been implicated in numerous outbreaks of
infection both in the UK and abroad. The Trust‟s Hand Hygiene Policy can be found here.

HPA: Health Protection Agency
Formerly the Public Health Laboratory Service, a national agency whose role is to protect the public from
infection and other hazards. The Head Office is in Colindale, London.

ICT: infection control team.
These are designated staff responsible for advising on hospital and community infection control. The team
usually consists of an infection control doctor (ICD), normally a consultant medical microbiologist and an
infection control nurse or nurses. The ICT has direct access to the hospital‟s chief executive, or their
representative and is responsible to the Infection Control Committee (ICC).


Infectious Diarrhoea
Infectious diarrhoea can be caused by many organisms including Escherichia coli sp, Salmonella sp,
Shigella sp, Campylobacter sp, to name but a few. These infections are associated with contaminated food
e.g poultry, and the mode of transmission is ingestion. Investigation of food borne infection must be
considered in an outbreak situation. Other causes of infectious diarrhoea to consider are Clostridium
difficile and Norovirus (viral diarrhoea).

Infection with Diarrhoea
The entry and multiplication of viruses and/or bacteria that enter the gut and cause loose watery, sometimes
offensive stools, which may be infectious.

Isolation room or unit:
A single room or unit often with its own hand washing and toilet facilities and also preferably with an
anteroom for healthcare workers to wash hands and don protective clothing, e.g., plastic aprons. The air
supply may be under negative pressure thereby maximising source isolation. Refer to Isolation Policy.

Morbidity:
The state of being ill and suffering: the sickness rate in a community or population.

Mortality:
The death of individuals in a population.

Narrow spectrum antibiotic
Can only be used against a limited number of bacteria.




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Outbreak of diarrhoea and/or vomiting
When three or more patients present with signs and symptoms of diarrhoea and /or vomiting not associated
with any underlying clinical condition in the same clinical setting
May be used to refer to a local cluster of cases or a small, limited outbreak.

Peri- operatively
Around the time of the operation.

Public Information
Timely and appropriate information to staff and public
    Flagging system on PHT Internet site flag symbols denoting level of outbreak occurrence, green,
        red or amber for each main site.
    Information leaflets for patients, staff and carers
    Enhanced signage – car parks, entrances and toilets etc.

Prevalence: (of a disease)
The total number of people with the disease at a defined point in time.

Protective Isolation
Confines the susceptible patients and prevents exposure to micro organisms by various routes (see
entrance signage attached to document) to be printed on green paper and laminated.




Pseudomembranous colitis: a super-infection of the gut resulting in the formation of a thick exudates (false
membrane) on the surface of the gut.

Risk Assessment at patient gateways to Hospital admission and transfer
Risk assessment of patient symptoms and history at patient gateways including A&E, MAU, PAU, SAU,
Urology and Gynae:
     Defined patient pathways if patient identified as a risk
     Adequate isolation facilities and application of enteric precautions for patient who becomes unwell
        during referral stage
     Defined patient pathway for high risk GP admissions
     Nursing Home/Residential Home involvement
     Liaise with Social Services
     Community Hospitals who may refer symptomatic infected patients for acute care.

Small round structured Virus (SRSVe.g. Norovirus or Rotavirus )
Norwalk – like virus, are the most common causes of outbreaks in hospitals and can also cause outbreaks
in other settings such as schools, hotels, residential and nursing homes and cruise ships.




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Source Isolation of patients:
Separation of patients with a disease or infection in an individual room in order to prevent or limit the direct
or indirect transmission of the disease or infection to other people who are susceptible. (see entrance
signage attached to document). To be printed on yellow paper and laminated.

Strategic approach to the prevention and control of outbreaks of D&V
Use of a clear escalation plan for a minor to major outbreak, this defines who makes decisions and
identifies triggers, early formation of Outbreak Committee, and establish robust communication/reporting
systems between key groups, SHA, HPA, neighbouring Trusts, Ambulance Trust, NHS Direct and NHS
Professionals.

Virulence:
The capacity of an organism to cause disease (also referred to as „pathogenicity‟).

6. PROCESS
6.1   The management of diarrhoea and/or vomiting requires commitment and adherence from the Trust
      and all clinicians involved. The effect on a patient and/or member of staff involved in an incident
      and/or outbreak of this kind can be far reaching. Therefore the management of the situation should
      by led by the Infection Control Team and supported by the key personnel in the Trust responsible
      for patient stay and their holistic care. Infection Control provide advice based on experience and
      research and follow procedures in place to safeguard all involved and to successfully bring the
      situation to a safe conclusion.

                  Each year an action plan is formed which identifies targets and actions required to prepare
         for the seasonal outbreaks which usually occur in the winter months and to identify the
         responsibilities of key areas.




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6.2   Transmission of Infectious Diarrhoea

         SRSVs may be spread by several routes: faecal – oral, vomiting/aerosols, food and water. Viruses
          may be introduced to the ward environment by any of these routes and then be propagated by
          person-to-person spread.
         Under certain conditions, the C difficile bacterium produces spores. These spores are resistant to
          heat, alcohol and acids in the stomach and can survive in patients and the surrounding environment
          for long periods of time. The environment of the hospital may become contaminated with spores
          from patients already infected, this places other patients at risk of contracting the infection
         Campylobacter enteritis – an acute bacterial enteric disease of variable severity characterized by
          diarrhoea, abdominal pain, malaise, fever, nausea and vomiting. The mode of transmission is by
          ingestion of the organism in under-cooked chicken and pork, contaminated food and water etc,
          human to human transmission is rare, but this highlights the requirement for good hand hygiene by
          all food handlers.
         Salmonella – a bacterial disease commonly manifested by acute enterocolitis, with sudden onset of
          headache, abdominal pain, diarrhoea, nausea and sometimes vomiting. Dehydration, especially
          among the elderly, may be severe. The mode of transmission is by ingestion of the organism in
          food derived from infected food-animals. This includes raw and undercooked eggs and egg
          products, raw milk and contaminated poultry and poultry products etc. this highlights the requirement
          for good hand hygiene by all food handlers.

6.2.1     Endogenous spread – When a person with infectious diarrhoea spreads the bacteria/virus from one
          part of their body to another. This spread can be reduced with good personal hygiene as the patient
          themselves is the carrier.

6.2.2     Exogenous spread – Person to person spread from direct contact with body fluids,
          vomiting/aerosols, food and water or environment. This spread can be reduced by hand washing
          and keeping the environment clean.

6.3       Local management of Diarrhoea and Vomiting
          Portsmouth Hospitals NHS Trust has adopted the local D&V Outbreak action plan, this document
          has been circulated and approved by Modern Matrons, Hotel Services, PAU,MAU, SAU and the
          Infection Control Committee. (Appendix 3).

          Targets set within the document are as follows
           Strategic approach to prevention and control of outbreaks of D & V
           Adequate hand hygiene by staff, patients, visitors and contractors.
           Bed management that ensures patient safety while responding to operational demands.
           The provision to isolate/cohort large numbers of affected patients while allowing operational
              capability
           Timely appropriate information to staff and public
           Risk assessment at patient gateways to hospital admissions and transfer
           Multi-disciplinary approach to outbreak management
           A regional early warning system
           Comprehensive application of defined infection control standards
           Multi-disciplinary management of affected staff ensuring appropriate work exclusion and timely
              return to work
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6.3.2    Escalation and flow of patients need to adhere to the escalation flow charts (Appendix 4).

6.4      Communication
         It is important that everyone is aware of the infection control precautions that need to be in place to
         manage D & V. For this to happen appropriate/ relevant staff involved in patient care/ interventions
         must be informed of the potential risks of the patients infective diarrhoea. In addition to thi s, daily
         outbreak updates are available on the Infection Control Intranet site, PHT Trust Internet site (flagging
         alert system in place) and via a daily update email on the list from the Trust distribution list.

         Healthcare staff must be empowered to provide the individual with appropriate information about D &
         V. This must be supported with the use of information leaflets. If the individual is an in-patient then
         healthcare staff must explain to patient and relatives that the patient has an infective diarrhoea and
         the rationale for further management e.g. the need for isolation / cohort until 72 hours clear from
         symptoms

         It is not necessary to disclose the D&V status of an individual to non-healthcare staff e. g
         domestic staff and porters. However these staff must be made aware of potential infection risk
         factors and they should make informed choices about the use of personal protection and
         equipment selection.

6.5      Patient Admission

6.5.1    Prior to admission / transfer to an inpatient facility a risk assessment most be performed to consider
         if the patient is known to have or had a history of diarrhoea and/or vomiting The risk assessment
         should ask:
          Is the patient known to be currently suffering from diarrhoea?
          Has the patient had a history of diarrhoea in the past?
          Has the patient come from a known outbreak /infectious clinical area?
          Has the patient recently had an inpatient stay in healthcare institution?
          Has the patient an existing contributing condition, that may present with diarrhoea?
          Has the patient been prescribed antibiotics?
          Has the patient an alternative method of feeding, e.g. PEG, Naso -gastric tube?
          Has the patient provided a recent stool specimen?
          Has the patient a known history of Clostridium difficile, with a positive stool in the past 28 days?
          Has the patient a history of vomiting?




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6.5.2 The environment that the patient is admitted to should also be considered. The following
      environmental factors should be considered:
       The type of hospital or facility:
       Tertiary referral, district general, single speciality, intermediate care
       The type of ward:
       Non-acute, acute, admission, intensive care or other high-risk unit
       The facilities available for patient isolation
       Ward design
       Availability of single room accommodation, „Nightingale‟, i.e., ope n-plan with no bays, wards
           with bays or cubicles.




6.5.3    Patients deemed to be high risk following the risk assessment should be standard source isolated
         (refer to Isolation Policy). The patient‟s medical and psychological welfare should not be
         compromised by unnecessarily restrictive infection control practices. The infection control team
         should be contacted in case of doubt. Individual single rooms (with en-suite facilities, if available)
         should be employed as the preferred standard of accommodation. Isolation Precaution signage
         should be used (see attached signage at the back of this document).

         The clinical needs of the patient are of paramount importance if neither a single room or cohort
         nursing are available then single bed barrier nursing with strictly enforced source isolation must be
         used.

            Priority order        Known patients with diarrhoea
                   1              Single room or cubicle within the specialty
                   2              To a cohort nursing area - refer to isolation nursing guidelines
                                  A single bed isolation area close to a clinical washbasin. Strict source isolation
                    3
                                  nursing MUST be enforced - refer to isolation nursing guidelines

6.5.4    The implications of a patient presenting with a history of signs and symptoms of diarrhoea should be
         explained to the patient and close relatives at the time of diagnosis and ideally prior to transfer to a
         side room, isolation unit, or designated area. Information leaflets should be available giving
         general information on diarrhoea in the language appropriate to the recipient. (These will be
         available from Infection Control).




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6.6   Patient movement and transfers

6.6.1    The movement of patients with diarrhoea within the Trust should be minimised to reduce the risk of
         cross infection, and any potential embarrassment for the patient. Where patients need to attend
         departments for essential investigations the receiving area should be notified of the patient‟s D & V
         status in advance of the transfer, and arrangements should be put in place to minimise the contact
         with other patients, i.e. to be called forward when the department is ready for them to ensure that
         they are not held in communal waiting areas. Staff should adopt isolation precautions whilst in
         contact with the patient. Arrangements for transfer to other healthcare facilities, e.g. hospitals, should
         include notification of the individual‟s D & V status, as appropriate and be made following advise
         from Infection Control Team.

6.6.2       No      Staff who are transferring patients must ensure that
             1      The receiving area is aware of the patient‟s D & V status.
                    If the patient is being moved to another ward/unit the receiving area has the appropriate
             2
                    level of isolation nursing available.
             3      If the patient is on antibiotics and/or stool chart these MUST be sent with the patient.
                    Portering staff who are transferring patients do not need to wear gloves provided they
             4      have intact skin however they MUST cleanse their hands before and after the job using
                    soap and water/alcohol hand gel.
                    Be transferred to a clean bed with clean linen or if a trolley or chair is used this must be
             5      cleaned with detergent followed by hypochlorite solution or with actichlor plus solution that
                    contains both components before being used for another patient.

         Ambulance staff must adhere to their own infection control policy.


6.6.3 Visits to out-patients and specialist departments within the hospital
Visits by D & V patients to other departments should be kept to a minimum. If this is necessary, either for
investigation or treatment, prior arrangements should be made with staff of the receiving department, so that
control of infection measures for that department can be implemented. These should include:
         Whenever possible D& V patients must be seen at the end of the working session
         Patients must be seen as soon as possible and not spend time in waiting area
         Staff who are giving direct hands on care must wear disposable aprons and gloves
         Equipment and the staff attending the patient should be kept to the minimal level without
               compromising the patient safety or care
         After the patient has left all surfaces which the patient came into contact should be cleaned
               with detergent followed by hypochlorite solution or with actichlor plus solution that contains both
               components
         Staff should decontaminate hands after contact with the patient.




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6.6.4 Transfer of D&V affected patients to other wards / departments/ hospitals
Transfer of D&V affected patients to other wards / departments should be minimised to reduce the risk of
spread, but this should not compromise other aspe cts of care, such as rehabilitation. Transport of the
infected/colonised patient should be carefully supervised. Before transfer of a patient they:
         Have their hygiene needs met
         Have clean clothing
         Be transferred to a bed with clean linen. The patient‟s o riginal bed and bed linen should be left
             behind on the ward for decontamination
         Lesions should be occluded whenever possible with an impermeable dressing.
         Attendants who may be in contact with the patient should wear disposable plastic aprons to
             protect their clothing whilst in contact with the patient.
         Aprons should be removed when contact with the patient has finished and disposed of as
             clinical waste.
         Gloves need only be worn if staff transporting the patient have skin abrasions, or if specifically
             instructed to do so by the nurse in charge or by the ICT.
         The trolley or chair should be decontaminated in accordance with local policy after use by the
             patient and before being used for another patient. All linen should be dealt with as infected, in
             accordance with local policy.
         Staff should decontaminate their hands thoroughly after dealing with the patient and cleaning the
             trolley or chair.

6.7     During the patient stay
The patient
         Must be actively encouraged to keep the bed space free from clutter to enable cleaning to be
            carried out to a high standard.
         Must be discouraged from keeping open food stuff at bedside.
         Must be actively encouraged to provide to maintain a stool chart and provide a stool specimen
            (specimen forms should indicate if viral and/or bacterial screen is required).
         Must be actively encouraged to observe good hand hygiene at every opportunity including
            using the alcohol hand gel at the bedside
         If identified as Clostridium difficile positive must be encouraged to wash using soap and wate r
            as alcohol gel is not affective against spores.




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6.8   Surgical interventions
      Eve ry effort should be made to eliminate D& V before surgery if this is not possible then the
      following strategy must be adopted
       D & V patients should be schedule for surgery at the end of theatre sessions, if this is not
           possible consult Infection Control Team.
       Bathe/shower the patient with antiseptic detergent e.g. chlorhexidene gluconate 4% prior to
           surgery
       All theatre surfaces in contact with the patient should be deco ntaminated post operation
           according to theatre policy
           D & V patients in recovery must be segregated wherever feasible and nursed by dedicated
           staff adhering to isolation procedures
       At the end of every operating session the table, anaesthetic and any other equipment must be
           cleaned using detergent solution, followed by hypochlorite solution (or actichlor plus) and
           dried.

6.9      Patient discharge
         D & V patients should be discharged promptly from hospital when their clinical condition allows.
          The General Practitioner and other healthcare agencies, including, if appropriate, Community
              Infection Control Teams, involved in the patient‟s care should be informed.
          D & V patients will not normally require special treatment after discharge from hospital. If a
              treatment course needs to be completed in particular circumstances the ICT should advise
              about this.
          If the patient is discharged to a residential care facility the medical and/or nursing staff should
              be informed in advance. The patient should be 72 hours free from symptoms in order to
              reduce the risk to the other residents of transmission of infection.
          Carers and visitors must be alerted to the risk of diarrhoea and/or vomiting infection, if visiting
              in a care facility and they themselves have been symptomatic they should be discouraged
              from contact until 72 hours clear also.

6.10     Deceased patients

         The infection control precautions for handling deceased patients are the same as those used in life.
         Any lesions should be covered with impermeable dressings. Plas tic body bags are not necessary,
         but may be employed as part of general practice in accordance with standard precautions for all
         patients. There is negligible risk to mortuary staff or undertakers, provided standard infection control
         precautions are employed. It is not necessary to inform the mortuary that the patient had D & V –
         Refer to Infection Control guidelines on the movement of the deceased patient.




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6.11 Cleaning of the patient environment and equipment

6.11.1 The management of the environment and equipment should be considered as central to minimising
       the spread of D & V. Cleaning regimens for isolation facilities should focus on the minimisation of
       dust, and the removal of fomites from contact areas, dust contains spores and other harmful
       organisms. It is therefore essential that dust levels are kept to a minimum. This should be a two -fold
       approach; firstly the management of the occupied facility, and then the terminal clean of the facility
       after the discharge of the patient. Patient equipment, e .g. wheelchairs, hoists, slings,
       sphygmomanometer cuffs, etc. should both be capable of being decontaminated, and to be
       decontaminated before use with other patients, or should be single patient use and discarded as
       clinical waste at the end of the period of usage.


6.11.2 The following is essential for maintaining a safe environment:
       The ability of Clostridium difficile spores to survive demonstrates the need for dust minimisation, the
       removal of fomites from contact surfaces, and the appropriate dis posal of contaminated waste and
       linen. Trust policies environmental cleaning and equipment decontamination, waste and linen
       management should state the necessary standards, and must be rigorously applied.

         Routine cleaning of the occupied facility: Inform Hotel Services of requirements
          Instruments or equipment (e.g. sphygmomanometers, stethoscopes, lifting slings, and
             physiotherapy exercise machines) should preferably be single patient use, or designated for
             D& V patients.
          Multiple-patient use items should be decontaminated appropriately before use on another
             patient in accordance with Trust policy or manufacturer‟s instructions.
          It is essential that clutter around the bed space is kept to a minimum to aid good nursing
             practice and facilitate cleaning
          Stains, soiling, food residue etc should be removed with a detergent solution – disinfectants
             on their own do not clean
          Lockers, over-bed tables and chairs should be cleaned daily with detergent. The bed frame
             should be wiped over daily with detergent. If the admission is more that two weeks wherever
             possible the patient should be given a clean bed and the current bed thoroughly cleaned with
             detergent.




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      Terminal Cleaning on patient discharge / transfer / death
      Enhanced levels of cleaning requiring additional time to enable the removal of all reservoirs of dust,
      e.g. ventilation ducts, radiators, equipments, etc. are required. Infected diarrhoea patient areas
      should be cleaned after the patient‟s discharge according to Trust policy, this includes:
       The bed space and all equipment must be thoroughly cleaned using detergent, thoroughly
           dried and then followed by a wipe over with hypochlorite solution (1000ppm) refer to Trust
           Policy.
       The removal and laundering of curtains.
       Pillows and mattress covers should be checked for damage.
       Therapy beds may need specialist cleaning in accordance with the manufacturer‟s/hirer‟s
           instructions.
       Additionally there should be planned, periodic and thorough cleaning of the whole ward,
           including bedding and curtains.

7.       DUTIES AND RESPONSIBILITIES
          Infection Control will work with Matrons, Clinical Directors, clinical leads, heads of specialties
             and infection control link persons to improve adherence to infection control guidelines /
             policies.
          All staff have a duty of care to the patients and themselves to ensure they deliver high
             standards of infection control practice at all times. Wherever there is deficiency in their
             knowledge or experience this must be highlight to the department/ward manager who is
             responsible for ensuring the member of staff receives the appropriate training, education or
             advice
          Matron, Clinical Directors. Clinical leads and heads of specialities have a duty of care to ensure
             staff receive education on and in all aspects of infection control which relate to their workforce‟s
             job.
          The Infection Control Team will monitor on a continuous basis the levels of D & V outbreaks
             across all sites.




              The Infection Control Team will monitor on a continuous basis levels of new cases of D & V
               across all healthcare areas. Where problems are identified work with the staff involved to
               improve the management of outbreaks
              Link advisors are responsible for auditing clinical practice and results should be fed back to
               Infection Control on a six-month basis. Infection Control are responsible for discussing with any
               area where remedial action is required
              Hotel Services and ward/department managers are responsible for auditing areas for
               cleanliness against the national standards. They should work together to resolve any issues
              The Patient Environment Action Group are responsible for carrying out the yearly Patient
               Environment Action Team audit




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8.    TRAINING
       Education on infection control is part of the induction for all staff
       Yearly up dates on infection control are available as part of the “Risky Business” mandatory
          training programme
       On-line Infection Control training available on Moodle (Internet site).

9.       ASSOCIATED DOCUMENTATION / REFERENCES (including related policies and procedures)

         Ayliffe G & English M (2003) Hospital Infection: From Miasmas to MRSA. Cambridge. University
         Press

         Chadwick et al (2000) Management of hospital outbreaks of gastro -enteritis due to small round
         structured viruses. Journal of Hospital Infection; 45;1-10.

         Department of Health. Winning Ways: Working together to reduce healthcare associated infection in
         England. Report from the Chief Medical Officer. 2003

         Hand Hygiene Task Force (2002) Guidence for hand hygiene in health-care settings.
         Recommendations of the Healthcare Infection Control Advisory Committee and the
         HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report,
         51(16), 1-48

         Harkness Gail A. Epidemiology in Nursing Practice. Mosby 1995, ch 12 , pages 209-225

         Healthcare Commission: Management, surveillance and prevention of Clostridium difficile, Interim
         findings from a national survey of NHS acute trusts in England. December 2005.

         Results of the first year of mandatory Clostridium difficle reporting: January to December 2004. CDR
         Weekly, Vol 15 No 34, 25 August 2005




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APPENDIX 1: Clostridium difficile

Clostridium difficile is a major cause of diarrhoea in hospital patients and is an important cause of healthcare
associated infections. It has been shown that antibiotic usage, environmental contamination and the patients
age are contributory factors in increasing the risk of the patient developing Clostridium difficle diarrhoea.

Clostridium difficile is an anaerobic, gram positive spore forming bacilli. These spores are resistant to
exposure to air, drying, heat and survive in the environment. Following antibiotic therapy the intestinal flora is
altered which allows the C difficile bacteria to proliferate. The bacteria produce two toxins:

       Toxin A which irritates the colon and causes what is commonly known as antibiotic associated
        diarrhoea, which can lead to pseudo-membranous colitis (PMC)
     Toxin B that is predominately cytotoxic
The source may be the patient themselves (endogenous) if they are the carrier or it can be acquired from
the environment (exogenous).

Clinical Practice Guidance
     Avoid unnecessary antibiotic usage.
     Use narrow spectrum antibiotics whenever possible following Microbiologists advice locally
     Use all antibiotics for as short a time frame as possible in line with the clinical need of the patient
     Stop or reduce all therapy which may alter gut flora, N.G feed for example may need to continue
     Send stool specimen to the laboratory for culture and C. difficile toxin testing.
     If patient is symptomatic, the patient will require single room isolation, explain rationale to both
        patient and visitors
     All healthcare staff, must be aware of their responsibility in taking the necessary infection control
        precautions to reduce the spread of infection
     Wear single gown and gloves when in contact with the patient or the environment
     Hands must be washed with soap and water before and after each patient contact as alcohol gel is
        not effective against Clostridium difficile spores
     Encourage good patient hand and toilet hygiene
     Encourage all visitors to follow hand washing process
     Clean all equipment with Actichlor plus which contains detergent and hypochlorite components,
        every day or when visibly contaminated
     Reduce clutter in and around the bed space to reduce contamination of horizontal surfaces and
        environment

Staff, patients and visitors all have a responsibility to reduce the risk of infection by keeping the bedspace
tidy to facilitate good nursing care and environmental cleaning.

Gastro-enteritis due to small round structured viruses
Small round structured viruses (SRSVs Norwalk-like viruses) are the most common cause of outbreaks of
gastro-enteritis in hospitals and also cause outbreaks in other settings such as schools, hotels, nursing
homes and cruise ships.

Hospital outbreaks often lead to ward closure and major disruption to hospital activity. Outbreaks usually
effect both patients and staff, sometimes with attack rates in excess of 50%. For this reason, staff shortages

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can be severe, particularly if several wards are involved at the same time. By the time an outbreak has
been recognised at ward level, most susceptible individuals will have been exposed to virus and infection
control efforts must prioritize the prevention of spread of infection to other clinical areas.

APPENDIX 2 : STOOL/VOMIT CHART

                                              STOOL/VOMIT CHART

PATIENT NAME:
HOSPITAL NUMBER:

 Date            Time          Type                           Description               Specimen         Initials
                                                                                          sent




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APPENDIX 3: D & V Outbreak Action Plan




                                                       PORTSMOUTH HOSPITALS NHS TRUST
D & V Outbreak Action Plan

Introduction
This plan will define the targets and the associated actions required to plan the operational and strategic management of potential outbreaks of diarrhea and/or vomiting within Portsmouth Hospitals NHS Trust.
Historically hospitals experience a higher incidence of outbreaks of this nature in the winter months, they are most commonly viral and have the ability to spread quickly from person to person causing an
increase in morbidity amongst the hospital patient and also lead to longer hospital stay.
Prolonged outbreaks over the winter can have an effect on all aspects of the patients‟ journey and planning is essential to facilitate this flow, this is the second annual plan and following the initial plan last summer
the Trust saw significant reductions in case numbers in staff and patients with symptoms and less bed days lost from ward closures(see below) The enclosed is a revision of this plan and includes actions to
facilitate an improved service this winter with a further reduction in cases as a satisfactory outcome.

                   Time Frame             Number of           Number of             Number of         Bed days          Average length of
                                          outbreaks             patients                Staff                                    outbreak
28/10/04 - 31/03/05                88                     2278                229                   715              7.06 days*
28/10/05 – 31/03/06                68                     612                 75                    586              8.61 days**
30/09/06 – 06/03/07                41                     365                 33                    353              8.6 days


Authors: Infection Control Team
Consultation Process includes:
Modern Matrons
Infection Control Management Committee (Formally Moving Forward together)
Hotel Services (Carillion)




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     Target                          Further Action                                                                   Lead                 Reviewed   Update
1    Strategic approach to           1.1   Revision of current escalation plan for minor to major outbreaks –         Trust / ICT          Dec 07     1.1 Re-issue to Matrons
     prevention and control of             define who makes decision, identify triggers.                                                              1.2 As required
     outbreaks of D & V              1.2   Early formation of Outbreak Committee                                      CE / DIPC / Cons                1.3 Ongoing
                                     1.3   Establish robust communication / reporting systems between key             Nurse                Dec 07
                                           groups, SHA, HPA, neighbouring Trusts, Ambulance Trust, NHS                ICT
                                           Direct, NHS Professionals
2     Adequate hand hygiene by        2.1 Hand hygiene leaflets, 2nd phase of cleanyourhands campaign                 ICT                  Dec 07     2.1 project managed by Debbie
     staff, patients, visitors and                                                                                    ICT / Estates                   Wilson, ICN
     contractors                      2.2 Signage at all entrances with technique and direction to nearest sink – 6                                   2.2 Re-issue to Matrons
                                          steps diagram available                                                                          Dec 07
                                                                                                                      Modern matrons /                2.3 Remind Matrons
                                      2.3 Accessible obvious alcohol dispenser stations at entrances –Patient         ICT
                                          personal issue alcohol –                                                    ICT                  Dec 07
                                                                                                                                                      2.4 Order no MRB 063 initially
                                                                                                                                                      contact Infection Control for an
                                      2.4 Individual gel for patients labelled and supplied during outbreak                                Dec 07     existing stock



3     Bed management that             3.1 Robust pro-active communication between infection control and bed           Bed Man. / ICT       Dec 07     3.1 Ongoing
     ensures patient safety whilst        management to establish outbreak contingency plan.                          Trust / MM / Bed
     responding to operational        3.2 Strict adherence to 72 hour exclusion rule for patients and 48 hours for    Man.                 Ongoing    3.2 Achieved during 2005-2006 winter
     demands.                             staff                                                                       ICT                  Ongoing    3.3 Ongoing as required
                                      3.3 Infection Control attendance at bed meetings at least once a day.           ICT                             3.4 Ongoing as required
                                          (During OB‟S and weekly out of season)                                      ICT / Bed Man.       Ongoing    3.5 Ongoing
                                      3.4 Continued use of outbreak reports.                                          DIPC / Director of   Dec 07     3.6 Regular contact with Mary Sherry,
                                      3.5 Clinical lead and Clinical Site Manager (CSM ) liaison in and out of        Nursing                         Head of Operations AND Maria Purse,
                                          outbreak status.                                                            Bed Man / ICT        Dec 07     PAU
                                      3.6 Senior Trust (Director Level) to empower infection control team and
                                          ensure adherence to the advice that is given during outbreak.                                               3.7 As required
                                          Provision of Consultant Microbiologist advice is available via              ICT                  Ongoing    3.8 Also available from ICT
                                          switchboard out of hours                                                                                    3.9 By arrangement and as required
                                      3.7 Patient transfer and movement are negotiated with infection control
                                          team.
                                      3.8 Outbreak packs reviewed and available on Trust Internet site                                     Dec 07
                                      3.9 ICN availability on site/by pager during weekends

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                                         3.10 Medical Microbiological cover out of hours via switchboard


     Target                              Further Action                                                                    Lead               Reviewed by   Update
4    The provision to isolate /          4.1   Identification of a medical and surgical decant ward / area.                Trust              Dec 07        4.1-4.2 Identify Trust Lead
     cohort large numbers of             4.2   Identifiable resources to service a decant area.                                                             4.3 Require formal written procedure
     affected patients whilst allowing   4.3   Written procedure on the opening / establishing a decant area.                                               4.5 Meeting to discuss variables if
     optimum operational capability.     4.4   Defined admission criteria to a decant ward                                                                  outbreak occurs on decant ward –
                                         4.5   Decant programme for refurbishment for PFI programme commenced              ICT/Kate Stewart   Dec 07        facility to keep closed and decant to
                                               August 17th 2006. Full clean and curtain change to be undertaken each                                        next available ward.
                                               8 weeks on changeover.
5    Timely appropriate information      5.1   Information leaflets for patients, staff and carers                         ICT, MM            Dec 07        5.1 Ongoing
     to staff and public                 5.2   Enhanced signage - car parks entrances, toilets. Web site                   ICT, Estates                     5.2 Car Park signage available will be
                                         5.3   Visitors kept to a minimum, 2 per patient at all times                                                       erected/removed by Estates on advice
                                         5.4   No Children visiting during October half-term holiday to be pro-active in                                    from ICT.
                                               reducing cross- infection from public                                                                        Hazard signs for entrances via ICT as
                                                                                                                                                            required
                                                                                                                                                            Daily outbreak update on Intranet
                                                                                                                                                            site Trust Internet site using traffic
                                                                                                                                                            light system of alert
                                                                                                                                                            5.3 Generally adopted throughout
                                                                                                                                                            Trust
                                                                                                                                                            5.4 Pro-active news paper article, link
                                                                                                                                                            web page etc




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6    Risk assessment at patient         6.1 Risk assessment at patient gateways including A & E, MAU, PAU, SAU,             ICT, MM, Bed Man.    Dec 07        6.1Escalation flow charts available
     gateways to hospital admission           Urology, Gynae                                                                Trust                              with pathways for known and/or
     and transfer. (Patient             6.2 Defined patient pathways if patient defined as a risk                                                Dec 07        suspected cases and care of new
     Movement Policy)                   6.3 Adequate isolation facilities and application of enteric precautions for        ICT, MM                            cases within clinical areas
                                              patient who become unwell during referral stage                                                    Dec 07        6.3 149 side rooms identified across
                                        6.4 Liaison with PCT lead to define GP risk assessment tool.                        D of N PCT,                        the Trust and use will require a risk
                                        6.5 Defined patient pathway for high risk patient GP admissions                     GP, Trust, ICT       Dec 07        assessment
                                        6.6 Nursing Home/residential home involvement and with social services                                   Dec 07        6.4 Ongoing with Ann Bishop, Senior
                                        6.7 Multidisciplinary Response Team, aims to provide a timely response to           ICT                                Nurse, IC, Community
                                              Health and Social Care crisis by providing short-term intensive                                                  6.5 Ongoing
                                              treatment and care to prevent acute hospital admission, crisis                                     Dec 07        6.6 Ongoing
                                              intervention and management and to facilitate and support early                                                  6.7Meeting with team, EHPCT and
                                              discharge from A&E and MAU                                                                                       Portsmouth team up and running.
                                       Community homes/hospitals etc may send in infected patients in to Acute                                                 Fareham and Gosport Team planned
                                       sector and vice versa, full clinical history required to ascertain risk assessment                                      for October 06
                                       prior to any transfers


     Target                            Further Action                                                                       Lead                 Reviewed by   Update

7    Multi- disciplinary approach to    7.1 Senior Trust support for outbreak management on a macro and micro               Trust                              7.1 Regular meetings with Hotel
     outbreak management                    level including daily support Agreed action plans with domestic services                                           Services, Mary Sherry (Operational
                                            prior to outbreak - cleaning and frequencies, communication, products,          ICT, MM, Dom         Dec 07        Manager) and ICT
                                            staff numbers                                                                   Services                           7.2 SOP for local cleaning with
                                        7.2 Domestic hit squads for any public episodes of vomiting in the public                                              Carillion
                                            areas                                                                                                              7.3 Hannah Keen, emergency linen
                                        7.3 Adequate supplies of linen, consumables, daily linen change                     Laundry, hotel                     available, new purchases with 24 hour
                                        7.4 Restrict visiting to maximum two per bed and only if visit essential.           services                           turn around delivery, does not
                                                                                                                            Patients Charter /                 include scrubs
                                       List of equipment and the associated cleaning responsibility                         Trust, MM            Dec 07        7.4 For action by Matrons
                                       Manager, Hotel Services


8     A regional early warning          8.1 Regional communication via Infection Control Nurses Association                 IC Cons Nurse        Dec 07        8.1 reviewed and active
     system                                 Wessex Branch                                                                   IC Cons Nurse
                                        8.2 Community alert via local Health Protection Agency                                                   Dec 07        8.2 reviewed and active
9    Comprehensive application of      9.1    Ratification and dissemination of Outbreak policy                             ICT, Trust           Dec 07        9.1 Ongoing
     defined infection control         9.2    Ratification and dissemination of Isolation policy                                                 Ongoing       9.2 Consultation stage
     standards                         9.3    Education and accessible information                                          ICT, MM                            9.3 Ongoing

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                                     9.4    Adequate provision of resources, hand washing, PPE, staff, side          MM                                 9.4 Liaise with Matrons
                                            rooms                                                                                         Ongoing
                                     9.5    Adherence to „Cleanyourhands‟ campaign                                   MM, ICT              Ongoing       9.5 Liaise with Matrons, ward
                                     9.6    Comprehensive Hand Hygiene policy adoption                               MM, Trust                          managers, new replacement bed
                                     9.7    Communication between Trust and infection control team.                                                     brackets available. Regular visits from
                                     9.8    Generation of a credible action following infection control advice                            Ongoing       GoJo (Purell) Trolley dash planned
                                     9.9    Credible evidenced based infection control advice                        MM, Clinical area                  9.6 Ongoing
                                     9.10   SOP for infection control team management of outbreaks, available to                                        9.7 Ongoing
                                            Trust                                                                    ICT                  Dec 07        9.8 As required
                                     9.11   Extended cleaning performed by all staff in clinical area – extra                                           9.9 Available as required
                                            hygiene vigilance de-clutter of ward areas                               MM                   Dec 07        9.10 Actioned
                                     9.12   Timely management and cleaning of body fluid spillages                                                      9.11 Matrons to action
                                                                                                                     Hotel services, MM   Ongoing       9.12 Matrons and Hotel Services to
                                                                                                                                                        action




     Target                          Further Action                                                                  Lead                 Reviewed by   Update




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10   Multi-disciplinary management   10.1    Issue of timely staff reminders of potential outbreaks and their        ICT, Link staff    Dec 07    10.1 As required
     of affected staff ensuring              management                                                                                           10.2 As required
     appropriate work exclusion      10.2    IT link pop up reminding staff of their responsibilities                ICT, IT
     and timely return to work       10.3    Link staff to raise profile in own areas, notice boards etc             Link staff, ICT    Dec 07    10.3 Ongoing
                                     10.4    Issue of outbreak packs to all clinical areas pro-actively and in
                                             response to an outbreak (also available on Intranet)                    ICT                Dec 07    10.4 As required additional pack
                                     10.5    Liaisons with Occupational Health to ensure affected staff are                                       available from ICT
                                             excluded appropriately and microbiological samples obtained.                                         10.5 MP met with Jan Robinson, staff
                                     10.6    Liaison with PAU and Modern Matrons to ensure wards adequately                                       yellow forms ppt ICT and copied to
                                             staffed.                                                                OC Health, ICT     Ongoing   OHD
                                     10.7    Trust guidance on the use of agency staff during an outbreak within     Bed Man, MM                  10.6 Discussed at bed meetings
                                             Outbreak Policy
                                     10.8    NHSP to produce guidance for staff prior to working in an outbreak                                   10.7 As above
                                             situation including alert systems to inform NHSP when staff may be      NHSP, ICT
                                             potentially a contact or symptomatic.                                                      Dec 07    10.8 NHSP comply with Company
                                     10.9    Minimal use of NHSP staff in affected areas. Increase                                                National IC Guidelines, copy held in
                                             communication                                                                                        IC office
                                     10.10   Use of NHSP staff to back fill clear areas to release Trust staff for                                10.9 As required
                                             affected areas                                                                                       10.10 As required
                                     10.11   Issue and comprehensive use of scrubs when a major outbreak
                                             declared – laundry to be informed, purchase extra scrubs.                                  Dec 07    10.11 Further debate required, as
                                     10.12   SOP for the use of scrubs / uniform during an outbreak. Uniform         Laundry, uniform             limited evidence in literature
                                             policy now ratified and available                                       policy                       10.12 As above
                                     10.13   Ward rounds on affected areas last on list.                                                          10.13 As required
                                     10.14   Tightly restricted staff movement between affected and unaffected       MM, Drs            Dec 07    10.14 As required
                                             areas.                                                                                               10.15 As required
                                     10.15   No staff back fill from affected areas to unaffected areas.             MM, Drs            Dec 07
                                                                                                                     MM
                                                                                                                                        Dec 07
                                                                                                                     MM




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Appendix 4: Escalation Plan
                                               One case of unexplained D&V
                                               (History of D&V in last 72 hours, sudden onset,
                                               not associated with other illness/medication)




                                                                     Source
                                                                    isolation
                                                 YES                                      YES


                    In ward                                                                                     In isolation unit


                                                                         NO
            If number of cases                               Cohort in bay
        increase to greater than 3                           designated area
                                                             (including contacts)




                                 If number of cases increase                    If no bays available




                                 > 2 cohort bays,                                 Close ward to admissions,
                                 Consider ward closure                               enteric precautions



                                 If number of cases increase                    If number of cases increase
                                 or more than one ward
                                 affected
        Escalation triggers

     Cannot be contained in side                    Establish clean decant, attempt one
      rooms/isolation unit                           bed closure in line with one bed
     2 bays used as cohort for contacts             opening within a Division
      and affected cases- ward closure
     3 associated wards closed within
      one division- outbreak committee
     2 associated wards closed –                                Cases decrease
      consider clean decant area
     Impact on surgical lists- consider
      clean decant, outbreak committee
                                                     If 72 hours clear in bay transfer
     Increase in virulence of organism-             patients back to clear bays
      increase in speed of spread
     Acuity of area affected                                                                                       NB:
     Evidence of increase in local activity                                                            Staff must be symptom free
      via local sources.                                                                                       for 48 hours
                                                                 All bays clear
     Resource limitations – staff absence


                                                     Open ward and close decant facility


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                                                  Local management of less than 10 cases of Diarrhoea and / or vomiting
                                                                       Three or more associated cases of D&V




                                                                                           Is source
                                                                       YES                  isolation                               NO
                                                                                           available?

                                                                                           Consider
                                                                Hand hygiene           Protective clothing, gloves, aprons
               Daily review
                                                                                              etc
                                                                  ↑Signage               Liaison with Infection Control                                  Able to cohort
                                                                                                                                                         nurse in bay?
                                                                                                                                                  YES
                                                                                                                   Consider
               72 hours                                                                                            dedicated
               clear?                                                                     Daily review             staff for
                                                                                                                   cohort area                                            NO
                                                                                                                                                         Isolation bed
                                                                                                                                                           available?
                YES                  NO                                                   72 hours
                                                                                          clear?
Ward open/                     Remain in
clean area                     isolation                                                                                                                 YES                      NO
                                                                                                                                          Daily review

                                                                                                                                                                          Cohort open
                                                                                            YES                    NO
                                                                               Clean                         Continue                                                        ward
                                                                                area                          cohort                          72 hours
                                                                                                                                               clear?
                                                    Consider:
                             Enhanced ward / department cleaning during outbreak
                             Focus on horizontal services – beds, door handles etc                                                      NO                                Consider
                             Discuss cleaning requirements with hotel services and IC                                                                                    ward closure
                             Ensure area cleaned after patient movement / discharge                                                           Clean     YES               – discuss
                                                                                                                                               area
                                                                                                                                                                            with IC
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                             An A&E Admission with Diarrhoea and / or Vomiting



                                                    History of diarrhoea
                                                  and/or vomiting in last 72
                                                           hours?
                           NO                                                                     YES




                     Process as normal.                                          Allocate separate waiting area or
                     Consider clean decant                                       straight to side room enteric
                     during major                                                precautions
                     outbreak.


                                 Consider
                               Hand hygiene
                                                                                 Ready for admission
                  Protective clothing, gloves, aprons etc
                                 ↑Signage
                      Liaison with Infection Control



                             Transfer check list:
                                     Gloves                                       Transfer to allocated /
                                     Aprons                             YES
                                                                                   dedicated side room /
                                     Mobile alcohol gel                            cohort bay on MAU /
                                     Vomit bowl/bag                                        SAU
                                     Swift transfer
                                     Single lift occupancy
                                     Receiving area pre-                                          NO
                                warned and ready




                                                                                     Able to transfer
                                                                                     to Isolation Unit
                                                                                     or ward side
                                                                                     room?
                             Consider:
            Enhanced ward / department cleaning during
           outbreak                                                                               NO
           Focus on horizontal services – beds, door
           handles etc                                                           Transfer to cohort bay
           Discuss cleaning requirements with hotel                             contact Infection Control
           services and IC                                                       Team. St Mary’s Ext 3270
           Ensure area cleaned after patient movement /
           discharge

                                                                                                  NO
                                                                               If cohort bay not available
                       Consider clean decant area              NO              consider admission to closed
                       in liaison with ICT                                     ward area (affected area).


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                               Admission to MAU with diarrhoea and / or vomiting


                                                  Does patient have history
                                                    of diarrhoea and/or
                                                  vomiting in last 72 hours?
                              NO                                                            YES




                     Process as normal.                                        Directly admit to
                     Consider clean decant                                     isolation area –
                     during major outbreak.                                    dedicated staff.


                                                                                             YES

                                                                               Ready for transfer


                     Transfer with                                                           YES
                     precautions to ward as
                     soon as possible.
                     Transfer check list:
                      Gloves
                      Aprons                                                   Is isolation room or
                      Mobile alcohol gel                                       cohort area on ward
                      Vomit bowl/bag                                                available?
                      Swift transfer
                      Single lift occupancy
                      Receiving area pre-
                        warned and ready

                                                                               Consider bed in an
                                                                      YES      affected area


                              Remember good infection control
                                         precautions:                          If no bed available in
                               Hand hygiene                                   affected area; patient
                               Use of PPE
                                                                                   should remain
                               Good hazard information signage
                               Information to patients, staff and                isolated on MAU
                               visitors
                               Liaison with infection control team
                               Adequate standards of cleaning                     Is patient                          NB:
                               Protect yourself and your patient                  symptom free                   Staff must be
                               Clear documentation – stool chart                  for 72 hours?               symptom free for 48
                                                                                                                      hours




                                                                               Continue isolation on
                                                                               MAU until ward bed
                                                                                     available


PHT Policy for the Management of Diarrhoea and Vomiting. Issue 2. 29.02.2008          Page 29 of 33     Control Date: 29/04/11
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL POLICIES: INFECTION CONTROL




PHT Policy for the Management of Diarrhoea and Vomiting. Issue 2. 29.02.2008   Page 30 of 33   Control Date: 29/04/11
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL POLICIES: INFECTION CONTROL


                                            SOURCE ISOLATION



PLEASE DO NOT ENTER THIS ROOM
BEFORE SPEAKING TO THE NURSE
IN CHARGE

PRECAUTIONS:

Gloves

Apron



        Prior to leaving room, please remove
        protective clothing and wash hands or
                clean with Alcohol gel

            Please do not visit if you are unwell


PHT Policy for the Management of Diarrhoea and Vomiting. Issue 2. 29.02.2008   Page 31 of 33   Control Date: 29/04/11
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL POLICIES: INFECTION CONTROL




                                        PROTECTIVE ISOLATION



PLEASE DO NOT ENTER THIS ROOM
BEFORE SPEAKING TO THE NURSE
IN CHARGE

PRECAUTIONS:

Gloves

Apron

Mask


        Prior to leaving room, please remove
        protective clothing and wash hands or
                clean with Alcohol gel

           Please do not visit if you are unwell
PHT Policy for the Management of Diarrhoea and Vomiting. Issue 2. 29.02.2008   Page 32 of 33   Control Date: 29/04/11
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL POLICIES: INFECTION CONTROL
Appendix 5: HPA Good Practice Guide




PHT Policy for the Management of Diarrhoea and Vomiting. Issue 2. 29.02.2008   Page 33 of 33   Control Date: 29/04/11

				
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