Viral Gastroenteritis Clinical Guidelines

• Summary
• Background
• Diagnosis
• Investigation
• Treatment/Management
• Appendix 1 - Procedure for the management of a single vomiting patient
  • Flow diagram 1 - Procedure for the management of a single vomiting patient
  • Flow diagram 2 - Procedure for the management of an increase in patient cases
  • Flow diagram 3 - Procedure for the management of a single case of diarrhoea
• Appendix 2 - Ward closure pathway in hours
• Appendix 3 - Ward closure pathway out of hours
• Appendix 4 - Behaviours and practices during a ward outbreak
• Appendix 5 - Sampling Procedures
• Appendix 6 - Procedures for environmental cleaning and decontamination of patient equipment including terminal cleaning
  and the removal of soiling and spillage
• Appendix 7 - Consumption of food and patient meal service
• Appendix 8 - Special instructions for visitors and relatives
• Appendix 9 - Vomiting & Diarrhoea - Medical Decision Support Document
• Appendix 10 - Treatment

Summary of Guideline

Actions to be taken to prevent transmission of Viral Gastroenteritis in the health care setting.

Aims

To prevent transmission of viral gastroenteritis within LTHT.
To ensure prompt action to identify and control an outbreak of viral gastroenteritis which will result in its rapid containment and prevent transmission to other departments.

Back to top

Background

Norovirus (previously Norwalk) is the most common cause of outbreaks of gastroenteritis in healthcare settings

• Norovirus has been estimated to cost the NHS in excess of £100million in years of high incidence. (Hoffman et al 2012)
• Viral Gastroenteritis can be spread via several different routes; faecal-oral, vomiting and aerosolisation and through contaminated food and water. Viruses may be introduced into the hospital environment via any of these routes and propagated by person to person spread, whereby hands are contaminated from the environment and virus ingested by mouth. Symptoms typically consist of nausea, diarrhoea and or vomiting, but may also include a fever, headache or abdominal pain. The condition is self–limiting with symptoms usually lasting between one to three days. During vomiting there is potential widespread contamination of the environment.
• Norovirus is highly transmissible requiring ingestion of as few as 10-100 viral particles to cause illness. The incubation period is usually 24-48 hours although as little as 12 hours has been reported.
• Although infectivity may precede clinical illness and viral shedding may be prolonged, the period of infectivity is considered to last from the onset of symptoms until 48 hours after the last episode of diarrhoea or vomiting.

Early identification of viral gastroenteritis is imperative to minimise person to person spread and subsequent transmission.
The following case definition must be used in the identification of Patient/s and or affected staff.

A SUSPECTED CASE OF VIRAL GASTROENETERITIS

Symptom
A Vomiting	One or more episodes of vomiting of a suspected infectious cause* occurring within a 24 hour period
B Diarrhoea	One or more loose stools (type 5-7) in a 24 hour period*
C Diarrhoea and Vomiting	One or more episodes of both symptoms occurring within a 24 hour period*

* Not associated with prescribed drugs or treatments and not associated with reaction to anaesthetics or underlying medical condition or existing illness

In addition to A B or C patients may also exhibit varying associated symptoms of nausea, raised temperature, headache and abdominal cramps.

= A, B or C with/without associated symptoms and microbiological confirmation.(HPA 03/10)

A SINGLE VOMITING PATIENT WITH SUSPECTED VIRAL GASTROENTERITIS OUT OF SEASON

Viral gastroenteritis season is generally regarded as at its peak during the winter months of the year (September to April)
If a patient vomits once but does not develop diarrhoea 24 hours after vomiting, a diagnosis of viral gastroenteritis is unlikely. Therefore, following thorough risk assessment in conjunction with the IPCT, source isolation or a bay closure may be discontinued.

Symptom	Duration	Action
Vomiting	Duration> 24 hours	Index case in isolation and bay closed.
Vomiting No diarrhoea	Vomiting only once with no diarrhoea within 24 hours No additional suspected cases identified	Bay to reopen/ Source isolation precautions lifted

CRITERIA FOR SUSPECTING AN OUTBREAK OF VIRAL GASTROENTERITIS

• 2 or more patients affected fitting the case definition that occurs in a ward or department within the hospital without laboratory confirmation.
• The following criterion acts as an indicator of a Norovirus outbreak in absence of laboratory confirmation:

1. Vomiting in >30% of cases
2. Affected patient(s) has/have had recent contact with viral gastroenteritis
3. Clinical features are highly suggestive of viral gastroenteritis (see case definition) e.g. rapid onset of symptoms and/or projectile vomiting
4. There is rapid spread of gastrointestinal infection, often affecting multiple patients, visitors, members of staff and students.
5. No bacterial agent found

Back to top

Diagnosis

Medical Support in regards to Assessment and Diagnosis of ViralGastroenteritis

There are no point-of-admission diagnostic tests that can determine the specific aetiologies of nausea and vomiting. The diagnosis of infectious gastroenteritis is based entirely on clinical assessment. Clinical assessment should be performed by a Nurse (Band 5 and above) or a Senior Doctor.
Inevitably some patients who are not isolated will turn out to be infected. As long as the decision has been made at an appropriate level and the reason for suspecting a non-infectious cause is documented in the patient’s notes it is reasonable for such patients not to be isolated. See Appendix 9 for further information.

Back to top

Investigation

STOOL SAMPLING
It is imperative that samples are obtained from all symptomatic cases.
Vomit may be submitted to the laboratory for Sampling.

Between the hours of 08.30 - 17.00, Monday to Saturday the IPC team and CSM can request Urgent Cepheid Norovirus Testing via the Enteric Laboratory. Utilisation of this test can usually provide results on the same day of receipt of sample (dependant on lab capacity). The aim of the rapid test is to support the Trust Infection Prevention Nursing team and Senior Management to release Ward bays, beds and discharge patients safely.

Clearance stool specimens are not required for patients with formed stools however sampling may be required in patients with prolonged symptoms. The requirement to provide clearance samples must be discussed with the Consultant Microbiologist and the patient’s clinician.

Back to top

Treatment / Management

ACTIONS TO BE TAKEN WHERE VIRAL GASTROENTERITIS IS CONFIRMED MICROBIOLOGICALLY

The nurse in charge should contact the IPCT in office hours and out of hours the ward should contact the Clinical Site Manager. A risk assessment will be carried out and advice provided accordingly.
If the ward is already fully closed subsequent confirmed cases do not need to be reported to the Consultant Microbiologist out of hours.
In the instance of a bay closure, cases identified outside of a closed bay must be notified to the infection control team.
Liquid soap and water to be used for decontamination of hands using the correct technique (See LTHT Hand Hygiene Policy).

ACTIONS TO BE TAKEN ON IDENTIFICATION OF TWO OR MORE CASES OF UNEXPLAINED DIARRHOEA AND/OR VOMITING

Senior nursing staff, in conjunction with medical staff (using the case definition) should make a decision as to whether viral gastroenteritis is the likely cause. If viral gastroenteritis is considered likely the IPCT should be informed immediately.

The procedures to be taken in the event of:
A Single vomiting patient in season (Appendix 1 flow diagram 1)
Escalation in patient cases (Appendix 1 flow diagram 2)
Single Case of diarrhoea only (Appendix 1 flow diagram 3)
Instigating a full ward closure in hours (Appendix 2) Instigating a full ward closure out of hours (Appendix 3).

DEFINITION OF A CLOSED AREA

In some cases the IPCT or on-call Consultant Microbiologist will recommend closure of all or part of the ward, and will inform the Matron for the area (or, if out- of-hours, clinical site managers). In broad terms a ward or bay closure means that there are no new admissions in or discharges out of the area, (unless cases are going to their own homes or in emergency situations), and where possible ward/bay activity and traffic is reduced to its absolute bare minimum to prevent spread to:

1. Currently asymptomatic patients on the ward
2. Visiting healthcare workers from other departments.
3. The rest of the hospital environment.
4. Visitors and relatives

There may however be some situations where there is a requirement to make an assessment of risk on a case by case basis. This will be undertaken by the Infection Prevention and Control department in conjunction with the CSU to continue to ensure patient safety and to maintain a service to patients across the hospital.

The pathways for ward closure both in and out of hours can be found in Appendices 2 and 3.

The following applies to wards, bays and other unit areas capable of segregation:

Closure refers to the restriction of incoming and outgoing personal equipment and materials to an avoidable minimum. The fewer times that the boundary of a closed area is crossed, the risk of ongoing transmission is significantly reduced.

There should be an obvious boundary between open and closed areas to signal to people that restricted access is in place. The boundary should consist of doors and high visibility signage.

Closed areas should be self-contained with access to hand washing facilities and its own dedicated washing and toilet facilities.

There must be no traffic of patients between the closed area and the open areas of the ward.

Patients should only be transferred for investigations and interventions that cannot be safely delayed.

	Admissions to a closed area must be restricted to:
A	Patients who are known to have been exposed to Norovirus or a have been identified as Norovirus positive within the previous 72 hours.
B	Patients who have been readmitted to hospital from a previously closed ward elsewhere in the trust up to 72 hours post discharge.
C	Exposed patients from wards where Norovirus has been confirmed microbiologically (2 or more confirmed cases)

Asymptomatic patients with no previous exposure must not be admitted to wards that are closed.

The decision to admit patients into a closed ward must not be undertaken without a prior risk assessment from the Infection Prevention and Control Team in hours or the on call Consultant Microbiologist out of hours.

All non-essential personnel should be prevented from entering a closed area. This includes, where possible, non-essential social visitors. (see Appendix 8 Visitors)

Dedicated medical, nursing and clinical support staff including housekeeping and volunteers should be assigned to closed areas for each work shift where
possible. If this is not achievable strict application of personal IPC measures (e.g. Strict hand hygiene and the use of personal protective equipment) as described in this guideline is essential.

ACTIONS TO BE TAKEN WHEN AN OUTBREAK IS DECLARED /

The Infection Prevention Nurse will visit and assess the ward 7 days a week during peak gastroenteritis season between the hours of 9am to 5 pm . The Clinical Site Manager should be contacted via switchboard for advice out of hours.
Depending on the individual circumstances the Infection Prevention & Control Team may consider it necessary to invoke the LTHT Control of an Outbreak of Infection in Hospital Guideline.

It is the responsibility of the nurse in charge to make sure that a ward closure notice is placed at all the entrance/exits to the ward and that all patients and relatives have access to information leaflet and hand decontamination.

It is the ward’s responsibility to ensure an accurate patient list is compiled, which also details members of staff and visitors. This information is vital in assisting the IPCT to undertake accurate risk assessment when they visit the ward. Ward documentation can be found at:
http://lthweb.leedsth.nhs.uk/sites/infection-control/ic-campaigns/infection-control-outbreak-plan/Ward%20record%20of%20outbreak%20doc.doc/view

Please refer to Appendix 4: Behaviours & Practices during a ward closure.

PREVENTING SPREAD TO OTHER CLINICAL AREAS.

Visiting staff e.g. Physiotherapists, Occupational Therapists, Phlebotomists should still continue their service to the ward. The affected ward(s) should be the last to be visited. Only essential procedures should be carried out on the symptomatic patients.

Staff in affected areas should not be transferred to other wards/departments. Agency staff should be discouraged from working on other wards if they have recently worked on an affected ward. It may be sensible to arrange for agency staff to work a block of shifts with days off 48 hours before returning to a non-infected ward.
Patients should not be transferred to other wards within the hospital, unless in an emergency, without consultation with the IPCT. If an internal transfer is necessary due to clinical need (e.g. to ICU or theatres), then a risk assessment will need to be undertaken, and the receiving unit should be informed and a side room requested.

Symptomatic patients should not be sent to diagnostic departments unless it is unavoidable. Where possible, investigations/treatments should be postponed or carried out at the patient’s location. If this is not possible, the receiving department should be informed so that they can make appropriate arrangements e.g. minimum time spent in the department, no contact with other patients and limiting the amount of staff who deal with the patient.

A patient’s treatment must not be compromised whilst the ward is closed due to viral gastroenteritis.

AVOIDING UNECCESSARY ADMISSION

A rise in the incidence of cases and outbreaks of Norovirus in institutions often reflects a similar increased incidence in the wider community it is important to keep the numbers of patients admitted to hospital with Norovirus to an absolute minimum. The following should be considered within the Accident and Emergency/Acute Assessment environments.

Immediate triaging in A+E of patients with vomiting and/or diarrhoea to a segregated area to prevent cross transmission to other patients within the department.

Patients should be routinely asked during triage if they have come into contact with anyone suffering with diarrhoea and vomiting within the previous 72 hours or they themselves have experienced/are experiencing symptoms currently. This assessment of risk must be clearly documented in nursing/medical notes.
Rapid clinical assessment of the patient by a sufficiently senior doctor
Where possible, the admission of patients will be restricted only to situations where the diagnosis is significantly uncertain or complications are a risk and simple rehydration is unlikely to suffice.

DISCHARGE OF PATIENTS DURING AN OUTBREAK
Discharge to own home

Patients can be discharged to their own home at any time irrespective of the stage of the patient’s Norovirus illness. It is not necessary to delay the discharge of symptomatic patients or those who may be incubating Norovirus. Care must be taken however to ensure the patient/ patient’s carer will be able to manage ongoing symptoms at home.

Patients from closed wards should not be placed in a discharge lounge whilst waiting for transport. Patients should be collected from the ward.

Should readmission be necessary, the patient should be advised to inform the admitting officer on return to the hospital.

Discharge to Nursing or Residential homes

Discharge to a nursing or residential home must not occur until 48 hours after the last documented patient case unless the patient has been affected and has been symptom free for at least 48 hours. However discharge to a home known to be affected by an outbreak at the time of transfer should not be delayed providing the home can safely meet the individuals care needs.

Discharge or transfer to other hospitals or community based institutions

This must be prevented until the patient has been asymptomatic for at least 48 hours. Urgent transfers to other hospitals need individual risk assessment and the Infection Prevention Team should be contacted.

WHEN IS THE PATIENT/WARD CLEAR OF INFECTION

Viral particles can be excreted before the onset of symptoms and for up to two weeks after recovery. However, transmission of infection is considered unlikely after more than 48 hours following the last episode of diarrhoea and/or vomiting. Therefore patients can be removed from isolation at this time.

During a ward closure, restrictions can usually be lifted 48 hours after the last patient has had any symptoms (NB: The IPCT must be involved in deciding whether any control measures can be relaxed).
A ward closure may be converted to a single bay closure if all remaining affected patients, less than 48 hours symptom free, can either be isolated in single rooms on the parent ward or cohorted in a bay area which is compliant with the definition of a closed area in p 4 of this guideline.

In some instances if two or more wards are affected by a confirmed Norovirus outbreak (confirmed from two or more samples in each area and during the latter stages of the outbreak) symptomatic patients can be cohorted on other wards to allow earlier cleaning and re-opening of an empty ward. The decision to admit patients into a closed ward must not be undertaken without a prior risk assessment from the Infection Prevention and Control Team in hours or the on call Consultant Microbiologist out of hours.

TERMINAL CLEANING

Norovirus has the ability to remain viable for up to 12 days in the environment therefore it is imperative that a thorough terminal clean is conducted before the ward can re-open.

Terminal cleaning should take place at least 48 hours after the onset of the final case and 48 hours since the last episode of uncontrolled vomiting/diarrhoea.(See Appendix 6 Procedures for environmental cleaning, decontamination of patient shared equipment including terminal cleaning and the removal of soiling and spillage).

AFFECTED STAFF

Staff of all disciplines, students and volunteers can all be affected during an outbreak of Viral Gastroenteritis.

All staff who become ill at work with either diarrhoea and/ or vomiting should be sent home immediately without completing the shift. It is their responsibility to inform colleagues that the bathroom/toilet area requires immediate decontamination. This is to prevent spread to other members of staff on the ward.

Any staff who are affected within LTHT MUST not return to work until a period of 48 hours has elapsed from their last symptom. The period of exclusion is to prevent further transmission to the hospital environment due to continued viral shedding which can occur up to 48 hours after symptoms have ceased.

Staff, Students and Volunteers working within LTHT are to be advised that this exclusion is mandatory.

The submission of staff samples is not required, unless it has been specifically requested by the Infection Prevention and Control Team following a risk assessment. Samples should be submitted via the individual’s GP. Advice and guidance can be sought from the Occupational Health team should this situation arise.

If staff have symptoms that reoccur they should be excluded from work and should not return until 48 hours have elapsed from their last symptom.

VISITORS

Visitors may contribute to ongoing spread of viral gastroenteritis. Where possible visitors should be discouraged from attending the wards that are closed due to viral gastroenteritis. This applies especially to elderly, immunocompromised or very young, in whom infections may be more severe/hazardous. The decision to cease visiting completely during an outbreak of viral gastroenteritis must be at the discretion of the Ward manager, Matron and/or Head of nursing for the CSU.

(See Appendix 8: Special instructions for visitors and relatives)

RE-OCCURING SYMPTOMS

Re-occurrence of symptoms may represent prolonged infection, re-infection or infection with a different organism.
The IPCT should be contacted immediately for a further risk assessment.
The patient/s should be isolated as soon as possible and the relevant pathway followed with IPCT advice.

Back to top

Appendix 1 - PROCEDURE FOR THE MANAGEMENT OF A SINGLE VOMITING PATIENT

• If a patient vomits and no clinical explanation can be given and an infectious agent is suspected, the patient must be isolated (where possible on the same ward) in accordance with LTHT Isolation Guideline. If isolation is not possible within 2 hours, the escalation procedure must be followed and a Datix incident form completed. (Please refer to Flow diagram 1 Procedure for a single vomiting patient)
• The existing bay must then be closed for 48 hours (the time period is to commence after the index case has been isolated) to cover the incubation period and prevent any further transmission. Curtains must be changed at the index cases bed space when he or she has been isolated and the bay thoroughly cleaned. This is to reduce the potential of cross contamination to other asymptomatic patients and curtail spread to the rest of the ward environment.
• If isolation cannot be achieved for the index case on the parent ward or a side room elsewhere within the same speciality, then the patient must remain in the closed bay. A Datix incident form must then be completed.

MANAGEMENT OF INCREASED NUMBERS OF PATIENT CASES (Period of increased incidence PII)

If another patient in the bay subsequently develops symptoms of vomiting before the index case is isolated, the bay should then be closed and no patient movement should occur. (See Flow diagram 2 Management of increased numbers of patient cases)

• Affected patients must be cared for using strict isolation precautions. (refer to the LTHT Isolation Guideline)
• When the capacity for the isolation of additional patient cases in side-rooms on the parent ward has been exceeded the decision to close the ward may be taken. The pathway for instigating a ward closure in hours can be found in Appendix 2 with the pathway for a ward closure out of hours can be found in Appendix 3.
• The ward following a risk assessment should be able to fulfil the required criteria on page 4 (Definition of a closed area).This is however subject to a risk assessment undertaken by the IPCT and the necessary stake holders.
• In areas where it can be demonstrated that symptomatic persons can be physically and safely separated from non-symptomatic individuals through cohorting it may not be necessary for the closure an entire ward or department
• Where cohort nursing is in operation within a bay area PPE should be worn and changed inbetween caring for each patient and hands must be decontaminated thoroughly with soap and water. (refer to the LTHT Isolation Guideline)
• Where there is more than a single case a list should be compiled, including members of staff and visitors, stating the symptoms and the date/time that these started. This information is vital in assisting the IPCT to undertake accurate risk assessment when they visit the ward. This can be found on the Infection Prevention and Control intranet http://lthweb/trust-news/sites/infection-control/infection-control
• There is no requirement to report to the IPCT additional cases as they arise on a closed ward either in or out of hours. Maximum precautions will have already been applied on instigation of the closure. Further cases will be monitored and documented during IPCT daily review
• In situations where additional cases occur in locations other than the initial cohort bay or side rooms the IPCT need to be informed immediately; risk assessment may indicate the need to progress to a full ward closure

SINGLE CASE OF DIARRHOEA ONLY

• There is no requirement to close a bay following a single case of diarrhoea unless this is in the context of an existing or suspected outbreak .The patient should be isolated in accordance with the LTHT Isolation Guideline and a sample obtained. The curtains from the vacated bed space should be changed and the bed space cleaned. If isolation is not possible within 2 hours, the escalation procedure must be followed and a Datix incident form completed. Further advice can be obtained from the Infection Prevention and Control Team in hours or the on call Consultant Microbiologist/ on call infection prevention and control nurse via the Clinical site manager. (refer to Appendix 1 flow diagram 3Single case of diarrhoea only)
• Should a subsequent patient in the bay develop symptoms of diarrhoea the patient, should also be isolated on the parent ward or a side room within the same CSU. If isolation is not possible within 2 hours, the escalation procedure must be followed and a Datix incident form completed. This may result in no patient movement occurring and the patient/s remaining in the bay.

Appendix 1

Back to top

Flow diagram 1: Procedure for the management of a single vomiting patient.

 

Back to top

Appendix 1 - Flow diagram 2: Procedure for the management of an increase in patient cases

(PII period of increased incidence)

Back to top

Appendix 1 - Flow diagram 3: Procedure for the management of a single case of diarrhoea

Back to top

Appendix 2- Ward Closure pathway in hours

Back to top

Appendix 3 - Ward closure pathway out of hours

Back to top

Appendix 4 - Behaviours and practices during a ward outbreak

Outbreak control measures
Ward	Close ward or bay to admissions and transfers Keep side rooms bay and ward doors closed Place signage on the ward door informing all visitors and staff of the closed ward status and restricted visiting
Patients	All patients on the ward (symptomatic and asymptomatic) should be commenced on the Bristol stool chart. This is to ensure that accurate information can be provided to the assist the Infection Prevention Team undertaking the daily risk assessment. Sample all symptomatic patients Provide adequate opportunity to allow patients to decontaminate their hands at regular intervals particularly prior to consuming food and post toileting
Healthcare workers	Ensure all staff are aware of the necessary control measures during a ward/bay closure. Allocate staff where possible to care for affected or non-affected patients. Ensure symptomatic staff refrain from work until they are 48 hours clear. Prevent nonessential clinical staff visiting the ward, i.e. medical students.
Patient and relative information	Provide all patients and relatives with information on Viral Gastroenteritis and the necessary control measures that they should follow Advise visitors on restricted visiting
Continuous monitoring and communication	Maintain an up to date record of all patients with symptoms and the number of staff affected Monitor all affected patients for signs of dehydration Ensure the CSU team is aware of the progress of the outbreak. Communicate to the wider multidisciplinary Team on a daily basis.
Personal Protective Equipment	Use apron and gloves as indicated to prevent cross transmission between patients. Personal Protective clothing (PPE) must be used when handling excreta or vomit and when in close patient contact. Aprons and gloves must be removed before leaving the patient’s immediate environment and hands should be decontaminated immediately (Please refer to LTHT Isolation Guideline).
Hand hygiene *See special considerations	Adequate facilities for hand hygiene must be provided: hand wash basins must be accessible and regularly restocked with soap and paper towels. To use liquid soap and water to decontaminate hands using the correct technique (See LTHT Hand Hygiene Policy). Encourage and assist patients to perform hand hygiene at regular intervals.
 Environment It is essential that Environmental cleaning is carried out to a high standard and cleanliness is maintained.	Remove exposed foods ( See Appendix 7 consumption of foods including meal service) Intensify cleaning ensuring affected areas are cleaned and disinfected Decontaminate frequently touched surfaces with detergent and 1000ppm available chlorine (Procedures for environmental cleaning, decontamination of patient shared equipment, including terminal cleaning and soiling and spillage can be found in Appendix 6 of this guideline)
Equipment All patient shared equipment must be thoroughly decontaminated and labelled as such in between uses to prevent person to person spread.	Use single patient equipment whenever possible. Decontaminate all non- disposable equipment after use. Ensure equipment is labelled and dated when clean. (Procedures for environmental cleaning, decontamination of patient shared equipment, including terminal cleaning and soiling and spillage can be found in Appendix 6 of this Guideline.)
Linen	Used and soiled linen from affected patients should be bagged and transported in accordance with LTHT Standard Infection Prevention and Control Precautions Guideline. Beds should not be remade until the ward is reopened; mattresses and bed frames must be thoroughly cleaned before remaking. Ensure adequate supplies of linen are available to the ward
Spillage Decontamination of all vomit or faecal spillage is vital to ensure viral particles are killed.	Clean and disinfect all faecal and vomit spillages using the biohazard spill kits follow Appendix 6 of this guideline Surgical masks should only be worn when clearing up vomit or faeces. * see special considerations and consider current COVID-19 PPE guidelines.

Back to top

Appendix 5 - SAMPLING PROCEDURES

• Stool specimens must be sent from all symptomatic patients. Diarrhoea can be defined as frequent, loose watery stools which on sampling takes the shape of the container and is described as type 5-7 on the Bristol stool chart
• The date and time the sample was obtained must be recorded in the outbreak documentation.
• Vomit may also be submitted to the laboratory for sampling if diarrhoeal sample not available.
• Contamination of a stool sample with urine does not affect specimen quality and should still be submitted for testing.
• Request forms should include MC+S (Microscopy, Culture and Sensitivity) and
  Virology” in Tests Requested and suspected outbreak in Clinical History.
• It is recommended to complete all forms and labelling of pots prior to obtaining the specimen. Hands should be washed thoroughly with soap and water using the correct technique afterwards. This will help to prevent cross contamination from your hands to the surrounding environment.
• There is no current requirement to provide clearance samples from patients with
  formed stools to define the end of an outbreak.

Back to top

Appendix 6 - Procedures for environmental cleaning and decontamination of patient equipment including terminal cleaning and the removal of soiling and spillage.

• The frequency of cleaning the ward environment must be increased (at least twice a day) using dedicated domestic staff and avoiding transfer of domestic staff to other areas.
• Regular additional checks of toilet and bathroom areas must occur throughout the day to prevent cross contamination from patient to patient.
• Clean from unaffected (clean) to affected (dirty)
• Disposable cloths must be used.
• If reusable microfibre mops are used they must be suitable for use with chlorine releasing agents and it must be ensured that there is a robust procedure for laundering these.
• Dedicate reusable cleaning equipment to affected areas and thoroughly decontaminate between uses e.g. mop handles and buckets using a suitable chlorine releasing agent.
• Special attention must be given to toilet and bathroom areas, commodes, all horizontal surfaces and frequently touched surfaces such as the nurses’ station, nurse call system, telephones, door handles/ push plates, sinks, taps and light switches. All surfaces should be cleaned and disinfected with a chlorine releasing agent at a concentration of 1,000ppm.
• It is not recommended that carpets are present in clinical areas due to their inability to be cleaned appropriately. Pre-existing carpets if soiled should be cleaned with a neutral detergent and warm water after removal of infective material. Effective disinfection is also achievable by steam cleaning. Vacuuming is not recommended.
• Cleaning staff and staff who undertake cleaning tasks should follow standard infection control precautions and wear appropriate personal protective equipment including disposable gloves and apron

TERMINAL CLEANING

• The Trust discharge cleaning procedure and its associated document must be used for every discharge clean.
• The facilities supervisors will distribute the appropriate colour coded cleaning equipment used for infection prevention and control purposes; the ward will ensure that an appropriate chlorine releasing agent is available to use.
• Discard unused disposable patient care items.
• Items that are not able to be cleaned appropriately must be discarded, including contaminated foodstuffs.
• Remove window and privacy curtains preventing unnecessary agitation and send for laundering (following LTHT Standard Infection Prevention and Control Precautions Guideline)
• Remove bed linen and any unused linen and send for laundering (following LTHT
  Standard Infection Prevention and Control Precautions Guideline)
• Decontaminate all equipment in accordance with manufacturer’s guidance.
• All surfaces should be cleaned and disinfected with a chlorine releasing agent at a concentration of 1,000ppm.

DECONTAMINATION OF SOILING AND SPILLAGE.

• Staff should wear appropriate PPE including disposable gloves and apron.
• Staff must use a biohazard spill kit to clear up the bulk spillage and discard into a dedicated waste bag.
• Clean the area with neutral detergent and hot water.
• Disinfect the area using chlorine releasing agent at a concentration of 10,000ppm in accordance with the manufacturer’s instruction.
• Dry the area thoroughly.
• Discard PPE and disposable materials into a dedicated waste bag.
• Wash hands with liquid soap and water.

DECONTAMINATION OF PATIENT SHARED EQUIPMENT

• Staff should wear appropriate PPE which includes disposable gloves and apron.
• Equipment must be cleaned in between uses with a chlorine releasing agent at a concentration of 1,000ppm.
• Equipment should be cleaned from the top to the bottom.
• Single use cloths should be used for each piece of equipment and discarded after use.
• Equipment should be dried thoroughly.
• PPE and disposable materials should be discarded into the dedicated waste stream.
• Hands washed with soap and water using the correct technique.
• Equipment to be labelled, dated and timed at the end of the cleaning process.

Back to top

Appendix 7 - Consumption of food and patient meal service.

Other than patient meals, food stuffs should not be consumed in the ward environment this is to prevent the risk of ongoing transmission of viral gastroenteritis from person to person.
Foods should not be shared or offered between colleagues or from patient to patient It is advised that the following is considered:

• Patients in affected bays should have open and exposed foods discarded
• Staff must not consume foods or beverages anywhere other than the staff room this includes food such as sweets, chocolates, biscuits and other confectionary.
• Staff and patient crockery (including patient meal trays) are thermally disinfected in an industrial dishwasher where the final rinse cycle reaches a temperature of
  82 degrees Celsius. Appropriate disinfection cannot occur by hand washing crockery.
• Meal service delivery should occur from Clean (asymptomatic patient areas) to dirty (symptomatic areas). Therefore closed bays and side rooms should receive meals last.
• It is suggested that a second member of staff will be required to assist in the delivery of patient meals to closed bays and side-rooms; this is to allow meals to be passed into an affected area, preventing unnecessary traffic and preventing the risk of cross contamination to the wider ward environment.
• Patients must be provided with the opportunity to decontaminate their hands at regular intervals particularly prior to consuming food.
• The same procedure should be adopted for the collection of meal trays (collecting from unaffected areas first and subsequently collecting from the affected area last). It is suggested that a designated cleanable trolley should be used to prevent trays being placed inappropriately on horizontal surfaces during collection.
• Aprons and gloves should be changed and hands washed with soap and water before entering the kitchen.
• At the end of the meal service the designated trolley should be cleaned with a chlorine releasing agent at a concentration of 1,000ppm.
• All horizontal surfaces in the kitchen should be wiped down.

Back to top

Appendix 8 - Special instructions for Visitors and Relatives

• Visitors should be advised not to visit if they have symptoms of gastroenteritis or have had recent contact with a person with diarrhoea and/or vomiting. This includes recent visits to other wards or departments affected with viral gastroenteritis.
• Visitors should decontaminate their hands on entering and leaving the ward by either hand washing (using liquid soap and water) or with alcohol hand rub if access to a hand wash basin is not possible without entering an affected area to do so.
• If clothing from symptomatic patients is returned to relatives or carers for laundering, they should be given verbal instruction on how to safely launder the items in the home setting.
• Soiled and contaminated clothing should be presented to relatives in a soluble bag placed inside a red bag. Specific laundry bags compatible with domestic washing machines are recommended.
• The Patient and Visitor Information Leaflet “Viral Gastroenteritis” should be given and made available to all patients and visitors to the ward (these should be ordered directly from the LTHT print unit code number WRU1006)

Back to top

Appendix 9 - Vomiting & Diarrhoea – Medical Decision Support Document

The causes of D+V that require source isolation are viral gastroenteritis , C. difficile infection and other enteric bacterial infections such as Salmonella and Campylobacter enteritis.

There are no point-of-admission diagnostic tests that can determine the specific aetiologies of nausea and vomiting. The diagnosis of infectious gastroenteritis is based entirely on clinical assessment. Decisions on patient isolation must be made by nursing staff at Band 5 or above or a senior Doctor .

Transmissible causes of vomiting and/or diarrhoea – patient needs to be isolated

Clinical features suggestive of viral gastroenteritis:

1. Sudden onset of vomiting
2. Recent exposure to other cases of vomiting or diarrhoea (e.g. in hospital, nursing home etc.)
3. Diarrhoea follows vomiting and usually lasts for 1-4 days
4. Clinical features suggestive of C. difficile infection:
   Diarrhoea, Bristol Stool 5-7 (unless this is the “normal” bowel habit of the patient), usually without vomiting.
5. Predisposing factor e.g. over 65 years, recent antibiotic use, immunosuppression, contact with known CDI cases.
6. Clinical features suggestive of other enteric infections:
   7. Diarrhoea (see above) with or without vomiting
   8. Cramping
   9. Abdominal pain.
   10. Bloody diarrhoea (especially with Campylobacter and E. coli O157)
   11. Fever.

Non-transmissible causes of vomiting and/or diarrhoea – isolation is not required

• Clinical features suggestive of a cause other than enteric infection:
• Serious sepsis from any cause (e.g. pneumonia, UTI, biliary sepsis, other intra- abdominal infection)
• Non-infectious condition e.g. bowel obstruction, pancreatitis, appendicitis.
• Central nervous system diseases that cause raised intracranial pressure.
• Known ingestion of toxic substance or recent change in medication.
• Pregnancy (especially early pregnancy)
• Bloodstained or coffee ground vomit.
• Prolonged vomiting over many days.

If the history and examination findings suggest an infectious cause for vomiting and/or diarrhoea the patient needs to be isolated. If the clinical features are more suggestive of a non-infectious cause isolation is not required. However if symptoms persist for over 48 hours, even if there is underlying condition or treatment that may cause the diarrhoea, then a sample should be sent in line with the Viral Gastroenteritis and LTHT CDI guidelines.

Back to top

Appendix 10 - Treatment

Dehydration

The mainstay of clinical treatment is the avoidance or correction of dehydration, which may be achieved through any standard oral rehydration regimen if tolerated. For those who are unable to take oral fluids, subcutaneous or intravenous administration of appropriate fluids is indicated. These measures are particularly important in the elderly and those with underlying conditions or illnesses.

Antiemetic

These should not be used. There is no current evidence for the efficacy of these drugs in adults and conflicting evidence for their use with paediatric patients for whom side effects may be an issue. There is also the risk of compromising IPC measures through masking the infectivity of patients

Anti-diarrheal drugs

Should not be used as these can be dangerous in some conditions such as Clostridium difficile infection. There is also the risk of compromising infection prevention & control measures through masking the infectivity of patients.