Management of an outbreak of viral gastro-intestinal illness Antibiotic Prescribing Policy Sepsis Policy

ENTERIC PRECAUTIONS

Infection Prevention Solutions

The three most important actions during an outbreak of diarrhoea and vomiting are:

• Effective hand hygiene • Isolation of affected patients, restriction of movement of staff, service users and visitors and exclusion of affected staff • Enhanced cleaning of the environment and equipment

EFFECTIVE HAND HYGIENE

Effective hand hygiene is vital to prevent transmission of infection and must be actively encouraged. Managers must ensure that staff are properly trained in hand washing technique and that they have easy access to hand hygiene facilities including warm water, liquid soap and paper towels. Plain liquid soap is adequate; antiseptic agents e.g. ‘Hibiscrub’ are not required for routine hand hygiene even during an outbreak.

Remember to always provide service users with hand-hygiene facilities i.e. detergent wipe or bowl of warm water, soap and towel after they have used a commode / toilet.

Please note:

Alcohol-based products e.g. alcohol gel / rub should NOT be used as a primary means of hand decontamination as this has been found to be less effective in viral outbreaks of gastro-enteritis. Soap and water should always be used initially and can be supplemented by the use of alcohol if required (but not essential).

MANAGEMENT OF SERVICE USERS (ISOLATION)

It is recognised that isolation of service users in mental health care settings can pose difficulties; however the need to protect others from infection is vital, where this is achievable. To gain co-operation control measures to be put in place should always be explained to the service user especially if they are required to stay in their bedroom.

It is necessary to isolate service users with symptoms of diarrhoea and/ or vomiting. This means they have to remain in their own bay or room i.e. away from others who are well (asymptomatic), and with their own toilet facilities and designated cleaning equipment. If en suite facilities are not available, specific toilet areas should be designated for their use only or commodes allocated for symptomatic service users only and stored separately. It is very important that strict isolation procedures are implemented by staff e.g. hand washing, enhanced environmental cleaning and safe handling of infected linen/ waste etc. for the duration of the illness. Service users should remain isolated until 48 hours after normal bowel habits have returned and/ or vomiting has stopped.

Infection Prevention Solutions

Segregation (cohorting) may be necessary in an outbreak when single rooms may not be available for all affected persons. In general, however, it is important that symptomatic people are kept apart from those that are asymptomatic. In practice, this means nursing affected service users in the same room or bay together and not admitting / transferring into empty beds in affected rooms / bays unless the service user (being transferred) is already symptomatic or has recovered from symptoms. Staff caring for affected service users should, where possible not care for asymptomatic service users where staff numbers allow. Seriously ill service users or the very frail elderly may be particularly vulnerable to acquiring norovirus, which may worsen their underlying medical condition. In such cases it is advisable to isolate these vulnerable service users in side-rooms (in effect, putting them into protective isolation) in order to minimise risk as much as possible.

All unnecessary items of equipment should be removed from rooms and bays to minimise the risk of contamination. This includes medical equipment and foodstuff such as fruit.

MOVEMENT OF SERVICE USERS IN AFFECTED AREAS

During an outbreak, service users should NOT leave the facility to visit other areas unless it is essential for their clinical management. This includes attending day care facilities, rehabilitation, outpatient appointments etc.

TRANSFERS OUT OF AN AFFECTED FACILITY

The transfer of any service users to another hospital or facility during an outbreak of diarrhoea and vomiting should be avoided other than in a medical emergency, and ideally the receiving unit / clinician should agree such transfers. This applies to symptomatic and asymptomatic service users (the latter may be incubating the virus). In such instances, staff MUST inform the receiving hospital and also the local ambulance Trust that they are transferring a service user from an area affected by diarrhoea and vomiting. This will allow ambulance personnel to take appropriate precautions and the receiving hospital to adequately isolate the service user on arrival thus minimising the risk of further spread.

DISCHARGES

Discharge to service users own home

Service users affected during an outbreak should not be discharged home until clear of symptoms for 48 hours. Those that have not been affected should ONLY be discharged home if the individual’s carer(s) are fully aware of the likelihood of him / her becoming symptomatic and feel able to cope in such a situation. Any community care providers e.g. district nursing team should be fully informed that the individual has been discharged from an affected facility so that they can make suitable arrangements to minimise the risk of spread e.g. visiting last in working day.

Infection Prevention Solutions

In certain circumstances it may be advisable to restrict / cancel all but essential visiting. This decision will be made on a case by case basis by the local HPU who will advise on the potential for increased spread within a community.

ENVIRONMENTAL CLEANING

Cleaning / housekeeping staff should be made fully aware of the outbreak situation and supervisory staff / managers notified immediately there is the suspicion of an outbreak, to ensure that they are able to respond to the increased demand for cleaning in the affected areas and for additional demand for cleaning supplies etc. Cleaning should be increased to twice daily in all areas, with a standard clean using detergent to be followed by a further clean of all areas using an appropriate disinfectant e.g. chlorine-based product. Alternatively a combined detergent / chlorine-based disinfectant solution such as Chlorclean or Actichlor can be used.

• Particular attention should be paid to “touch points” – toilet handles, taps, door handles, light pulls etc.

• A chlorine-based disinfectant at a strength of 1,000ppm (0.1%) should be used to decontaminate all surfaces after washing the area with warm water and detergent

• Alternatively use a combined detergent / chlorine-based disinfectant solution e.g. Chlorclean

• Staff must be aware of and comply with COSHH regulations when using a chlorine-based product

• All cleaning cloths used during an outbreak must be disposable and discarded after each use. Strict attention should be paid to correct colourcoding of cleaning equipment. If possible, yellow equipment should be used in those rooms deemed to be isolation areas

• Do NOT use the same cleaning equipment in rooms of both symptomatic and non-symptomatic service users. Ideally a separate cloth, mop-head and bucket should be used for each area / room. If not, then use one set of equipment in rooms of symptomatic service users and a separate set of equipment in unaffected rooms

• Mop heads must be laundered daily or discarded at the end of the day

• Where service users are isolated or in cohort bays, these areas must be cleaned LAST at the end of ward cleaning, and cloths disposed of in the clinical waste bin in that room / bay

• Aprons and gloves used in affected areas must be disposed of in the clinical waste bin in that room / bay when removed

Infection Prevention Solutions

SPILLAGES (See also Spillages section)

Spillages should always be dealt with immediately. Chlorine should not be used on urine as fumes may be released. Protective clothing (gloves and apron) should be worn whilst cleaning spills, and discarded immediately afterwards as clinical waste.

DECONTAMINATION OF MEDICAL EQUIPMENT

(See also Decontamination of Medical Equipment section)

Where possible, all medical equipment should be dedicated for use by individual service users (or groups of affected service users) during an outbreak. If this is not feasible, then all equipment MUST be adequately decontaminated after use with detergent and water followed by a chlorine-based disinfectant solution (or an appropriate wipe) and then thoroughly dried with paper towels.

This is of particular importance for equipment such as commodes, wheelchairs, moving and handling equipment etc. that may come into contact with contaminated body fluids. Such items of equipment must be routinely decontaminated after each

and every use during an outbreak of gastro-intestinal infection.