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Viral Gastroenteritis Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 1 of 10
Viral Gastroenteritis Guidance
Post holder responsible for Procedural Document
Lead Nurse/Director Infection Prevention& Control
Author of Guideline Judy Potter
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 Operational Group: 19th November 2015
Review date (and frequency of further reviews)
May 2018 (every 3 years)
Expiry date November 2018
Date document becomes live 23rd November 2015
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 Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 2 of 10
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
8.1 10th Jul 2017 Lead Nurse Intranet links updated
Associated Policies:
Source Isolation Policy & Procedures for Hospital Patients Ward Closure Policy due to a Suspected or Confirmed Outbreak of Infection Outbreak Control Policy
In consultation with and date: Infection Prevention & Control Team: 29/08/2015 Consultant Microbiologists:29/08/2015 Infection Control Operational Group: 19th November 2015
Review Date (Within 3 years)
May 2018
Contact for Review:
Lead Nurse, Infection Prevention & Control
Executive Lead Signature: (Only applicable for Strategies & Policies)
N/A
Viral Gastroenteritis Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 3 of 10
CONTENTS 1. INTRODUCTION ........................................................................................................ 4
2. CLINICAL FEATURES .............................................................................................. 4
3. TRANSMISSION ........................................................................................................ 4
4. CONTROL OF SPORADIC CASES ........................................................................... 4
5. BAY AND WARD CLOSURE ..................................................................................... 4
6. CONTAINMENT OF CASES ...................................................................................... 5
7. HAND HYGIENE ........................................................................................................ 5
8. PERSONAL PROTECTIVE CLOTHING .................................................................... 5
9. KITCHEN ACCESS.................................................................................................... 6
10. DISCHARGES AND TRANSFERS ............................................................................ 6
11. MOVEMENT OF STAFF BETWEEN WARDS ........................................................... 6
12. ENVIRONMENTAL DECONTAMINATION ................................................................ 6
13. RELATIVES AND VISITING ...................................................................................... 6
14. STAFF........................................................................................................................ 7
15. ENDING OF PRECAUTIONS ..................................................................................... 7
16. REFERENCES ........................................................................................................... 7
APPENDIX 1 - MANAGEMENT OF PATIENTS WITH DIARRHOEA AND VOMITING IN AMU, ED OR OTHER ADMISSION AREAS .............................................................. 8
APPENDIX 2 - RAPID IMPACT ASSESSMENT SCREENING FORM ................................. 9
Viral Gastroenteritis Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 4 of 10
1. INTRODUCTION 1.1 Viral gastroenteritis is an infection of the stomach and intestine, commonly caused
by Norovirus, leading to symptoms of diarrhoea and vomiting. 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 guidance is based on the national guidelines (2012) and local experience.
2. CLINICAL FEATURES 2.1 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.
3. TRANSMISSION
3.1 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.
4. CONTROL OF SPORADIC CASES
4.1 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, 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. Cases presenting in admission areas, please refer to management guidance in Appendix 1.
5. BAY AND WARD CLOSURE 5.1 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.
5.2 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 could sustain the outbreak. Stopping admissions to affected areas has demonstrated that they reopen more quickly.
Viral Gastroenteritis Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 5 of 10
5.3 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.
5.4 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.
6. CONTAINMENT OF CASES 6.1 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.
6.2 Symptomatic cases are generally considered to have resolved when they have had
no further symptoms for 48 hours or more.
7. HAND HYGIENE
7.1 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. 7.2 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 washed with 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.
8. PERSONAL PROTECTIVE CLOTHING 8.1 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.
Viral Gastroenteritis Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 6 of 10
8.2 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. These do not take the place of personal protective clothing which must still be worn for direct contact as above. Essential staff visiting the ward 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 documents page within outbreak information on the Trust Intranet.
9. KITCHEN ACCESS 9.1 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 documents page within outbreak information on the Intranet
10. DISCHARGES AND TRANSFERS 10.1 During ward closure, transfers of patients to other wards, hospitals or nursing
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.
11. MOVEMENT OF STAFF BETWEEN WARDS 11.1 Staff working between affected and non-affected areas within a period of duty would
normally be discouraged (refer to Ward Closure Policy). 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.
12. ENVIRONMENTAL DECONTAMINATION 12.1 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.
13. RELATIVES AND VISITING 13.1 Temporary closure of a ward or bay is required to prevent and control the risk of
viral gastroenteritis illness spreading in the RD&E hospital 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
Viral Gastroenteritis Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 7 of 10
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.
13.2 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. 13.3 Wards should display the ward/bay closure signs notifying all visitors of the
outbreak and provide the RD&E Trust 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.
14. STAFF 14.1 Staff with gastroenteritis should 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 certain bacterial infections, clearance specimens may be necessary before an individual can return to work.
15. ENDING OF PRECAUTIONS 15.1 The decision to re-open affected areas will be made by the Infection Prevention and
Control Team in liaison with clinical and managerial staff.
16. REFERENCES Guidelines for the management of norovirus outbreaks in acute and community
health and social care settings. Public Health England 2012
Viral Gastroenteritis Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 8 of 10
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 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/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 with strict isolation precautions in place.
Whilst on AMU/ED strict isolation precautions must be maintained for patients with D&V i.e. isolation card on door with required precautions indicated side room door closed number of people entering room kept to the necessary minimum commode allocated, if patient unable to use en-suite toilet staff to wear gloves and aprons on entry to room gloves and aprons removed prior to leaving the room unless transferring body
fluids to dirty utility room for disposal hands washed with soap and water prior to exit from room ( or in dirty utility
room if as above) 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.
Viral Gastroenteritis Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 9 of 10
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: 29/08/2015
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?
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 ☐ ☒
Viral Gastroenteritis Guidance Ratified by: Infection Control Operational Group: 19
th November 2015
Review date: May 2018 Page 10 of 10
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.)?
Please specify any groups you think may be affected in any significant way
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:
