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Viral Gastroenteritis Policy Ratified by: Infection Control & Decontamination Assurance Group: 3
rd August 2017
Review date: February 2022 Page 1 of 13
Viral Gastroenteritis Policy
Post holder responsible for Procedural Document
Judy Potter, Lead Nurse/Director Infection Prevention& Control
Author of Guideline Judy Potter, Lead Nurse/Director Infection Prevention& Control
Division/ Department responsible for Procedural Document
Specialist Services, Infection Prevention & Control
Contact details Extension number x2690
Date of original guideline 1997
Impact Assessment performed Yes/No
Ratifying body and date ratified Infection Control and Decontamination Assurance Group: 3rd August 2017
Review date (and frequency of further reviews)
February 2022 (every 4 ½ years)
Expiry date July 2022
Date document becomes live 10 October 2017
Please specify standard/criterion numbers and tick other boxes as appropriate
Monitoring Information Strategic Directions – Key Milestones
Patient Experience Maintain Operational Service delivery
Assurance Framework Integrated Community Pathways
Monitor/Finance/Performance Develop Acute Services
CQC Fundamental Standards Regulation No.: 12 Infection Control
Other (please specify):
Note: This policy has been assessed for any equality, diversity or human rights implications
Controlled document This document has been created following the Royal Devon and Exeter NHS Foundation Trust Development, Ratification & Management of Procedural Documents Policy. It should not be altered in any way without the
express permission of the author or their representative.
Viral Gastroenteritis Policy Ratified by: Infection Control & Decontamination Assurance Group: 3
rd August 2017
Review date: February 2022 Page 2 of 13
Full History
Status: Final
Version Date Author (Title not name)
Reason
1.0 1997 Lead Nurse New guideline
2.0 2003 Lead Nurse Routine revision
3.0 2005 Lead Nurse Routine revision
4.0 Sept 2007 Lead Nurse Routine revision
5.0 Aug 2009 Lead Nurse Routine revision
6.0 Oct 2011 Lead Nurse Routine revision
7.0 Nov 2013 Lead Nurse Routine revision
8.0 Aug 2015 Lead Nurse Routine revision
9.0 July 2017 Lead Nurse Routine revision harmonised with community services requirements
Associated Trust Policies/Procedures:
Source Isolation Policy & Procedures for Hospital Patients Ward Closure Policy due to a Suspected or Confirmed Outbreak of Infection Outbreak Control Policy
Key Words Ward closure, Outbreak, Gastroenteritis, Infection, Norovirus, Winter vomiting disease, Small round structured virus, D&V
In consultation with and date: Full membership of the Infection Control and Decontamination Assurance Group which includes representation from the executive team, divisional management teams (including community services), nursing and medical staff, therapists, facilities, operations support, estates and Public Health England’s Devon/Cornwall and Somerset Local Team: 3rd August 2017 Policy Expert Panel (PEP): 15th August 2017.
Contact for Review:
Lead Nurse, Infection Prevention & Control
Executive Lead Signature: (Only applicable for Strategies & Policies)
Medical Director
Viral Gastroenteritis Policy Ratified by: Infection Control & Decontamination Assurance Group: 3
rd August 2017
Review date: February 2022 Page 3 of 13
CONTENTS 1. INTRODUCTION ........................................................................................................ 4
2. PURPOSE .................................................................................................................. 4
3. DEFINITIONS............................................................................................................. 4
4. DUTIES AND RESPONSIBILITIES OF STAFF ......................................................... 4
5. CLINICAL FEATURES .............................................................................................. 5
6. TRANSMISSION ........................................................................................................ 5
7. CONTROL OF SPORADIC CASES ........................................................................... 6
8. BAY AND WARD CLOSURE ..................................................................................... 6
9. CONTAINMENT OF CASES ...................................................................................... 6
10. HAND HYGIENE ........................................................................................................ 7
11. PERSONAL PROTECTIVE CLOTHING .................................................................... 7
12. KITCHEN ACCESS ................................................................................................... 7
13. DISCHARGES AND TRANSFERS ............................................................................ 8
14. MOVEMENT OF STAFF BETWEEN WARDS ........................................................... 8
15. ENVIRONMENTAL DECONTAMINATION ................................................................ 8
16. RELATIVES AND VISITING ...................................................................................... 8
17. STAFF........................................................................................................................ 8
18. ENDING OF PRECAUTIONS ..................................................................................... 9
19. ARCHIVING ARRANGEMENTS ................................................................................ 9
20. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY/ STRATEGY ......................................................................................... 9
21. REFERENCES ......................................................................................................... 10
APPENDIX 1: MANAGEMENT OF PATIENTS WITH DIARRHOEA AND VOMITING IN AMU, ED OR OTHER ADMISSION AREAS ............................................................ 11
APPENDIX 2: EQUALITY IMPACT ASSESSMENT TOOL ............................................... 12
Viral Gastroenteritis Policy Ratified by: Infection Control & Decontamination Assurance Group: 3
rd August 2017
Review date: February 2022 Page 4 of 13
1. INTRODUCTION 1.1 Viral gastroenteritis is an infection of the stomach and intestine, most commonly
caused by Norovirus, leading to symptoms of diarrhoea and vomiting (D&V). The disease was historically known as “winter vomiting disease” due to its seasonality and typical symptoms. It is also known as small round structured virus (SRSV) or Norwalk-like virus. Within the general community circulation of Norovirus is common, causing sporadic or small clusters of cases. Large outbreaks can occur in semi-closed settings such as hospitals, nursing/residential homes, schools and hotels. Other viruses may cause diarrhoea and vomiting especially rotavirus, which is commonly seen in children (see Source Isolation Policy & Procedures for Hospital Patients).
1.2 This policy is based on the national guidelines (Public Health England, 2012) and
local experience. 1.3 Failure to comply with this policy could result in disciplinary action
2. PURPOSE 2.1 The purpose of this policy is to minimise the risk of the spread of viral gastroenteritis
in hospital amongst patients, staff and visitors.
3. DEFINITIONS
Viral gastroenteritis - refer Introduction for definition
Cohort bay - a group of patients who are isolated together in a bay rather than individually in single rooms.who either all have signs and symptoms of gastroenteritis, or laboratory diagnosis of norovirus (or another causative virus) or who have been exposed to viral gastroenteritis
4. DUTIES AND RESPONSIBILITIES OF STAFF 4.1 Chief Nurse is responsible, through the Assistant Directors of Nursing and
Senior Nurses for:
Ensuring that there is adequate nursing staffing and expertise to provide care for patients with suspected or confirmed norovirus when required
4.2 Medical Directors and Associate Medical Directors are responsible for: Ensuring that relevant medical staff are aware of this document and the relevant information within it.
4.3 Infection Prevention and Control Team (IPCT) is responsible for:
Advising that patients with suspected or confirmed norovirus are isolated appropriately
Acting as a resource for best practice for clinical staff
Monitoring compliance through patient placement auditing
Viral Gastroenteritis Policy Ratified by: Infection Control & Decontamination Assurance Group: 3
rd August 2017
Review date: February 2022 Page 5 of 13
4.4 Ward Matrons are responsible for:
Ensuring that all relevant nursing staff are aware of the need to isolate patients with suspected or confirmed viral gastroenteritis and implement the procedures contained in this document
Ensuring that hand hygiene, the use of Personal Protective Equipment (PPE), equipment decontamination and ongoing environmental cleaning standards are maintained to minimise the risk of cross infection
Ensuring that single rooms or cohort bays and wards are terminally cleaned after use by patients with suspected or confirmed viral gastroenteritis
4.5 Other Medical and Nursing Staff are responsible for:
Maintaining standards of hand hygiene and the use of PPE for the prevention of transmission of infection
4.6 Microbiology Department is responsible for:
Providing a diagnostic and clinical advice service
Ensuring that results are communicated promptly to clinical teams 4.7 Site Management Team is responsible for:
Ensuring isolation facilities are provided promptly when the need is identified 4.8 Housekeepers and Domestic Services are responsible for:
Maintaining standards of environmental cleanliness
Providing terminal cleaning following suspected or confirmed viral gastroenteritis
4.9 All Staff
It is the responsibility of all staff to:
Promote good infection control practice
Have the necessary knowledge and skill to perform the tasks they are required to do
5. CLINICAL FEATURES 5.1 Viral gastroenteritis has an incubation period of between 12-72 hours, with most
people becoming symptomatic within 48 hours. The onset of symptoms may be gradual or abrupt. Symptoms can include diarrhoea, vomiting (which may be projectile), abdominal pain, headaches, and low-grade fever. Symptoms are self-limiting and generally last for between 24-72 hours. Collection of stool or vomit samples for virology may facilitate diagnosis.
6. TRANSMISSION
6.1 Viral gastroenteritis may be transmitted from person to person directly via the
faecal-oral route. Widespread aerosol dissemination of virus particles produced during vomiting or explosive diarrhoea cause environmental contamination and subsequent indirect person to person spread. Transmission can also take place by exposure of oral mucous membranes to aerosols of vomit.
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rd August 2017
Review date: February 2022 Page 6 of 13
7. CONTROL OF SPORADIC CASES
7.1 All cases of suspected infectious diarrhoea need to be isolated in a single room
preferably with en-suite facilities and must be nursed in accordance with the Source Isolation Policy. Where possible within the Royal Devon and Exeter Wonford site (hereafter referred to as RD&E [Wonford]), single rooms on Torridge Ward should be used as these are both negative pressure and, in most cases, lobbied. Prompt transfer to Torridge Ward of positive cases can prevent ward outbreaks. For cases presenting in admission areas, please refer to management guidance in Appendix 1. Elsewhere, the patient should be isolated in a single room as previously stated with en-suite facilities.
7.2 Community nursing teams can provide support to patients in their own homes to
avoid unnecessary admission unless clinically indicated. Symptomatic patients should be advised not to visit Minor Injuries Units (MIU) or General Practice (GP)
surgeries in person.
8. BAY AND WARD CLOSURE 8.1 Norovirus has a considerable propensity to spread within hospitals resulting in ward
or hospital-wide outbreaks. Success in limiting outbreaks depends heavily on early recognition of those who may be infected in order that appropriate action can be taken.
8.2 Temporary closure of a bay or ward is sometimes required to prevent any further
spread of the illness (Please refer to D&V Outbreak pack documents available on the Intranet). Although individual cases are only infectious for a few days, the regular introduction of new patients who are susceptible to infection will sustain the outbreak. Stopping admissions to affected areas has demonstrated that the outbreak will be curtailed more rapidly.
8.3 The Infection Prevention and Control Team (IPCT) should be notified immediately when cases are suspected particularly when they arise in a previously asymptomatic part of the ward. All suspected cases and their symptoms should be listed on the ward outbreak sheet available in the D&V Outbreak pack. Outbreaks of viral gastroenteritis can often be diagnosed presumptively on clinical grounds from the presenting clinical features and the occurrence of both symptomatic staff and patients making effective documentation vital.
8.4 Other policies and guidelines supporting outbreak situations include the Ward Closure Policy due to a Suspected or Confirmed Outbreak of Infection and, when there are multiple closures, the Outbreak Control Policy.
9. CONTAINMENT OF CASES 9.1 When an outbreak is suspected it is imperative that control measures are
implemented immediately. Affected patients i.e. those who are symptomatic or who have been nursed within the same bay as those with symptoms must be isolated appropriately. This may be within single rooms preferably with en-suite facilities or within a designated cohort bay, which has an allocated toilet or designated commode facilities. Typically, it may take up to 24 - 48 hours before those exposed develop any symptoms and it is imperative that those patients who are potentially incubating the infection are not transferred from these areas until after this time or after consultation with the Infection Prevention and Control Team.
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rd August 2017
Review date: February 2022 Page 7 of 13
9.2 Symptomatic cases are generally considered to have resolved when they have had no further symptoms for 48 hours or more.
10. HAND HYGIENE
10.1 Single rooms:
In addition to routine hand hygiene at the point of care, hands should be washed with soap and water after removing personal protective equipment prior to leaving the isolation room.
Once outside the isolation room repeat hand hygiene with hand rub gel. 10.2 Cohort bays:
Hands should be cleaned at the point of care prior to the use of clean non-sterile gloves (see below).
Hands should be cleaned with alcohol gel or soap and water between contact with different patients within a closed bay
Where patient zones are being accessed for chart reviews/ bedside record updates only, gel can be used between bed spaces.
Hands must be washed with soap and water, following removal of gloves and aprons, prior to leaving the cohort bay or after disposing of body fluids in the dirty utility room. Other surfaces must not be touched with contaminated hands or gloves in the meantime.
11. PERSONAL PROTECTIVE CLOTHING 11.1 The environment will be contaminated with virus particles, therefore gloves and
aprons must be donned on entry to the side room or cohort bay and worn for all direct patient contact and handling of linen/patient moving and toileting equipment. Within cohort bays, staff must continue to change aprons and gloves between contacts with different patients.
11.2 Personal protective clothing should continue to be worn when transporting body
fluids from affected areas to the dirty utility room, then removed and disposed of. If an outbreak is confirmed, raspberry coloured scrubs suits will be provided for all
staff working in the area to wear (within the RD&E Wonford site only). These do not take the place of personal protective clothing which must still be worn for direct contact as above. Essential staff visiting affected wards on the Wonford site must also change into scrubs if they intend to be in the area for more than 30 minutes. Where staff visiting for shorter periods need to access areas where patients are actively symptomatic, the wearing of scrubs should also be considered. The Standard Operating Procedures for the use of scrub suits can be found on the Infection Control page within the ‘D&V Outbreak Documents’ on the Trust Intranet.
12. KITCHEN ACCESS 12.1 Kitchens and food service represent an additional risk during outbreaks and access
to the kitchen should be restricted to the least exposed staff. Guidance regarding access to kitchens and food service can be found on the Infection Control page within the “D&V Outbreak Documents” on the Intranet.
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rd August 2017
Review date: February 2022 Page 8 of 13
13. DISCHARGES AND TRANSFERS 13.1 During ward closure, transfers of patients to other wards, hospitals or nursing/care
homes should be avoided unless indicated due to clinical need and following consultation with the IPCT. If transfers have to take place, the receiving unit must be notified of the situation on the ward in order that appropriate infection control measures can be taken. Discharges to patients’ own homes can go ahead.
14. MOVEMENT OF STAFF BETWEEN WARDS 14.1 Staff working between affected and non-affected areas within a period of duty would
normally be discouraged (refer to Ward Closure Policy due to a Suspected or Confirmed Outbreak of Infection). Use of bank and agency staff should be minimised wherever possible. If staff movement is unavoidable, a change of uniform and, preferably, a shower is required before working in a non-affected area. Doctors and other peripatetic staff e.g. phlebotomists and physiotherapists, should either be designated to work on affected areas only or order their work load so that they visit unaffected areas prior to visiting affected areas.
145 ENVIRONMENTAL DECONTAMINATION 15.1 Following discharge of a patient or an outbreak on a ward the environment must be
thoroughly decontaminated. Please refer to the terminal cleaning guidelines in the Source Isolation Policy & Procedures for Hospital Patients or terminal cleaning poster on the ward.
16. RELATIVES AND VISITING 16.1 Temporary closure of a ward or bay is required to prevent and control the risk of
viral gastroenteritis illness spreading in the RD&E hospitals and community. If a ward is closed with confirmed cases of Norovirus, normal visiting arrangements for the entire ward area are suspended. Patients will be allowed a named visitor each day who may visit in the afternoon and/or evening for 30 minutes. Please seek advice from the IPCT. When a bay is closed, restrictions on visiting apply to that bay only. Clearly, exceptions to these restrictions are necessary for children, critically ill patients, dying patients and those with special needs. The ward matron/sister will ensure that these exceptions are identified and visiting allowed. Restriction exemption cards can be printed and distributed to named visitors on a case by case basis.
16.2 Visitors should be advised to wash their hands with soap and water upon leaving a
closed bay/room and not to eat or drink whilst in the affected area. 16.3 Wards should display the ward/bay closure signs notifying all visitors of the
outbreak and provide the RD&E’s letter for patients and visitors – ‘Viral Gastro-enteritis ward closure visitor Information (Found on the Infection Control page on the Intranet) and provide the trust leaflet ‘Viral gastroenteritis (diarrhoea and vomiting) information for patients and visitors’.
17. STAFF 17.1 Staff with gastroenteritis must remain off duty until 48 hours have elapsed from their
last symptom. In certain cases i.e. in those who have returned from foreign travel, whose symptoms are persistent or unusual e.g. bloody diarrhoea, or where there is the need to investigate a cluster of cases, a stool specimen may be required. After
Viral Gastroenteritis Policy Ratified by: Infection Control & Decontamination Assurance Group: 3
rd August 2017
Review date: February 2022 Page 9 of 13
certain bacterial infections, clearance specimens may be necessary before an individual can return to work.
18. ENDING OF PRECAUTIONS 18.1 The decision to re-open affected areas to admissions and lifting other control
measures will be made by the Infection Prevention and Control Team in liaison with clinical and managerial staff.
19. ARCHIVING ARRANGEMENTS The original of this policy will remain with the author Lead Nurse, Infection
Prevention and Control. An electronic copy will be maintained on the Trust Intranet, P – Policies (Trust-wide) – V – Viral Gastroenteritis Policy. Archived electronic copies will be stored on the Trust's “archived policies” shared drive, and will be held indefinitely. A paper copy (where one exists) will be retained for 10 years.
20. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY
20.1 To monitor compliance with this policy, the auditable standards will be monitored as
follows:
No Minimum Requirements Evidenced by
1. Patients are appropriately placed on wards so as to minimise the risk of infection to others
Annual audit of patient placement
2.
The decision to re-open affected areas to admissions and lifting other control measures will be made by the Infection Prevention and Control Team in liaison with clinical and managerial staff.
Lack of datix reports identifying lack of compliance with this requirement
20.2 Frequency
In each financial year, the Infection Prevention and Control Nurse Specialist will audit patient placement to ensure that this policy has been adhered to and a formal report will be written and presented at the Infection Control and Decontamination Assurance Group.
20.3 Undertaken by Monitoring will be undertaken by the Infection Prevention and Control Team 20.4 Dissemination of Results
At the Infection Control Operational Group which is held quarterly and at the Infection Control and Decontamination Assurance Group which is held quarterly.
20.5 Recommendations/ Action Plans
Implementation of the recommendations and action plan will be monitored by the Infection Control Operational Group, which meets quarterly.
20.6 Any barriers to implementation will be risk-assessed and added to the risk register.
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rd August 2017
Review date: February 2022 Page 10 of 13
20.7 Any changes in practice needed will be highlighted to Trust staff via the Governance Managers’ cascade system.
21. REFERENCES Public Health England (2012) Guidelines for the management of norovirus
outbreaks in acute and community health and social care settings. [online]
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rd August 2017
Review date: February 2022 Page 11 of 13
APPENDIX 1 - MANAGEMENT OF PATIENTS WITH DIARRHOEA AND VOMITING IN AMU, ED OR OTHER ADMISSION AREAS
On admission, the diarrhoea and vomiting assessment will be completed for all patients. This will help to identify patients who have had symptoms in the previous 48 hours and those who have been exposed to someone else with symptoms in the last 48 hours.
The Nurse in Charge will review all patients in single rooms on the Acute Medical Unit (AMU) on at least a daily basis to determine whether they require single room accommodation. The IPCT can be contacted for advice either by phoning the office ext. 2355 Mon-Fri, or by contacting the on-call Infection Prevention and Control Nurse (evenings and weekends).
Patients admitted with active D&V and those who have had symptoms in the preceding 48 hours will be assessed in a side room on AMU/Emergency Department (ED) and, if other causes for the symptoms cannot be established, it must be assumed that Norovirus infection is the most likely cause.
If Norovirus infection is suspected and the patient needs to remain in hospital, he/she will usually be transferred to a single room on Torridge ward within 4 hours of admission to AMU/ED. NB. Wherever possible, direct admission to a Torridge isolation room is preferred.
If the patient with suspected Norovirus infection needs to be admitted to a specialist unit, rather than Torridge, they must be admitted to a single room on the appropriate unit/ward ideally with en-suite facilities and strict isolation precautions maintained.
Whilst on these admission areas strict isolation precautions must be maintained for patients with D&V i.e.
o isolation card on door with required precautions indicated o side room door closed o number of people entering room kept to the necessary minimum o commode allocated, if patient unable to use en-suite toilet o staff to wear gloves and aprons on entry to room o gloves and aprons removed prior to leaving the room unless transferring body
fluids to dirty utility room for disposal o hands washed with soap and water prior to exit from room ( or in dirty utility
room if as above) o patient’s relatives should be advised of risk of infection, and told to:
wash their hands prior to leaving the room, not to eat and drink in room avoid hand to mouth contact
Patients who have been exposed to D&V prior to admission may be in the incubation period and must be admitted to a single room, on the most appropriate medical ward. Isolation precautions must be applied. If the patient remains asymptomatic isolation precautions may be lifted after 48 hours. This information must be communicated to the receiving ward by the AMU/ED nurse arranging the transfer.
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rd August 2017
Review date: February 2022 Page 12 of 13
APPENDIX 2: EQUALITY IMPACT ASSESSMENT TOOL
Name of document Viral Gastroenteritis Guidance
Division/Directorate and service area Specialist Services / Infection Prevention
and Control
Name, job title and contact details of
person completing the assessment
Judy Potter, Lead Nurse/Director
Infection Prevention and Control
Date completed: 21/07/2017
The purpose of this tool is to: identify the equality issues related to a policy, procedure or strategy summarise the work done during the development of the document to reduce
negative impacts or to maximise benefit highlight unresolved issues with the policy/procedure/strategy which cannot be
removed but which will be monitored, and set out how this will be done.
1. What is the main purpose of this document?
To ensure there is a clear framework for recognition, reporting, investigation and control of Viral Gastroenteritis
2. Who does it mainly affect? (Please insert an “x” as appropriate:)
Carers ☒ Staff ☒ Patients ☒ Other (please specify)
3. Who might the policy have a ‘differential’ effect on, considering the “protected
characteristics” below? (By differential we mean, for example that a policy may have a noticeably more positive or negative impact on a particular group e.g. it may be more beneficial for women than for men)
Please insert an “x” in the appropriate box (x)
Protected characteristic Relevant Not relevant
Age ☐ ☒
Disability ☐ ☒
Sex - including: Transgender,
and Pregnancy / Maternity ☐ ☒
Race ☐ ☒
Religion / belief ☐ ☒
Sexual orientation – including:
Marriage / Civil Partnership ☐ ☒
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rd August 2017
Review date: February 2022 Page 13 of 13
4. Apart from those with protected characteristics, which other groups in society
might this document be particularly relevant to… (e.g. those affected by homelessness, bariatric patients, end of life patients, those with carers etc.)?
None
5. Do you think the document meets our human rights obligations? ☒
Feel free to expand on any human rights considerations in question 6 below.
A quick guide to human rights:
Fairness – how have you made sure it treat everyone justly?
Respect – how have you made sure it respects everyone as a person?
Equality – how does it give everyone an equal chance to get whatever it is offering?
Dignity – have you made sure it treats everyone with dignity?
Autonomy – Does it enable people to make decisions for themselves?
6. Looking back at questions 3, 4 and 5, can you summarise what has been done
during the production of this document and your consultation process to support our equality / human rights / inclusion commitments?
Please give a brief summary- identifying:
1.) Consulted with the Infection Control Operational Group
7. If you have noted any ‘missed opportunities’, or perhaps noted that there remains some concern about a potentially negative impact please note this below and how this will be monitored/addressed.
“Protected
characteristic”: None
Issue:
How is this going to be
monitored/ addressed in
the future:
Group that will be
responsible for ensuring
this carried out: