Outbreaks of Suspected or Confirmed Norovirus Policy - V7.0 December 2018 - RCHT

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Outbreaks of Suspected or Confirmed Norovirus Policy - V7.0 December 2018 - RCHT
Outbreaks of Suspected or Confirmed
         Norovirus Policy

               V7.0

          December 2018
Summary. Norovirus Flowchart

                             Patient has developed sudden
                                    onset diarrhoea.

                    Complete diarrhoea risk assessment tool.
                        Is infective cause suspected?

                           NO                                  YES

                     Isolation not                          Is Norovirus
                       required                             suspected?

                                                      YES                  NO

        Isolate patient in side room on the                         Isolate patient
         same ward                                                    in side room
        Obtain specimen                                                Complete
                                                                     terminal clean
        Close the bay                                                of bed space
        To determine the need to keep the
         bay closed, prompt review of the
         situation is required by:
            o In hours – IPAC, Nurse in
              charge, consultant /medical
              team
            o Out of hours – site coordinator,
              on-call microbiologist,
              consultant /senior doctor

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
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Table of Contents

Summary. Norovirus Flowchart ............................................................................................ 2
1.     Introduction ................................................................................................................... 5
2.     Purpose of this Policy/Procedure .................................................................................. 5
3.     Scope ........................................................................................................................... 5
4.     Definitions / Glossary .................................................................................................... 7
5.     Ownership and Responsibilities .................................................................................... 7
     5.1.      Role of General Managers/Clinical Leads ............................................................. 7
     5.2.      Role of Wards Sisters/Charge Nurses and Departmental Managers..................... 7
     5.3.      Role of Individual Staff ........................................................................................... 7
     5.4.      Role of Ward Staff – action card number 14 .......................................................... 7
     5.5.      Infection Prevention and Control (IPAC) Team – action card number 9 ................ 8
     5.6.      Role of Microbiology Department .......................................................................... 8
     5.7.      Role of Occupational Health Department .............................................................. 8
     5.8.      Role of the Hospital Infection and Control Committee ........................................... 8
     5.9.      Role of the Outbreak Control Group ...................................................................... 8
     5.10.        Role of the Clinical Site Co-ordinators – Action card ......................................... 8
6.     Standards and Practice ................................................................................................ 8
     6.1.      Ward Management ................................................................................................ 8
     6.2.      Personal Protective Equipment (PPE) ................................................................. 10
     6.3.      Hand Hygiene ...................................................................................................... 10
     6.4.      Patient Movement................................................................................................ 10
     6.5.      Staff ..................................................................................................................... 11
     6.6.      Ward Staff............................................................................................................ 12
     6.7.      Ward Cleaning ..................................................................................................... 12
     6.8.      Visiting ................................................................................................................. 12
     6.9.      Ward Re-opening ................................................................................................ 13
     6.10.        Communication ................................................................................................ 13
     6.11.        Escalation Procedure ....................................................................................... 13
7.     Dissemination and Implementation ............................................................................. 13
8.     Monitoring compliance and effectiveness ................................................................... 14
9.     Updating and Review.................................................................................................. 14
10.         Equality and Diversity .............................................................................................. 14
Appendix 1. Governance Information ................................................................................ 15
Appendix 2. Initial Equality Impact Assessment Form ....................................................... 18
Appendix 3. Escalation Levels ........................................................................................... 21
Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
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Appendix 4. Outbreak Form - Patients ............................................................................... 22
Appendix 5. Outbreak Form - Staff .................................................................................... 23
Appendix 6. Bristol Stool Chart .......................................................................................... 24
Appendix 7. Terminal Clean Sign-off Form ........................................................................ 25
Appendix 8. Norovirus Action Card – ED Staff................................................................... 27
Appendix 9. Norovirus Action Card – IPAC Team ............................................................. 28
Appendix 10. Norovirus Action Card – Medical Staff ......................................................... 29
Appendix 11. Norovirus Action Card – Clinical Site Co-ordinators..................................... 30
Appendix 12. Norovirus Action Card – Support Staff (Porters, Supplies, etc.) ................... 31
Appendix 13. Norovirus Action Card – Therapies Staff/Pharmacists ................................. 32
Appendix 14. Norovirus Action Card – Ward Staff ............................................................. 33
Appendix 15. Norovirus Action Card – Domestics ............................................................. 34
Appendix 16. Action Card Housekeepers .......................................................................... 35

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
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1. Introduction
      1.1. Norovirus is a major cause of acute gastroenteritis and diarrhoea in children
      and adults. The cause of illness, Norovirus (previously known as Norwalk-like or
      Small Round Structured Virus) was described in 1968 in samples from an elementary
      school in Norwalk, Ohio. The disease is often termed Winter Vomiting Disease
      because of the increased prevalence in the winter months; however it can be
      detected throughout the year.

      1.2. Norovirus is the most common cause of outbreaks of gastro-enteritis in
      hospitals and can also cause outbreaks in other settings such as schools, nursing
      homes and cruise ships. Hospital outbreaks often cause major disruption in hospital
      activity resulting ward closures, cancelled admissions and delayed discharges which
      can significantly reduce clinical activity for the duration of the outbreak. Failure to
      observe and comply with Infection Control guidelines/policy can lead to further
      spread of infection and a delay in the hospital returning to normal activity. Outbreaks
      can affect both patients and staff, sometimes with attack rates in excess of 50%. For
      this reason, staff shortages can be severe, particularly if several wards are involved
      at the same time. It is therefore essential that cases are detected early and isolated
      appropriately to prevent spread and major outbreaks.

2. Purpose of this Policy/Procedure
      This policy has been developed to provide a practical document to equip all
      healthcare staff at the Royal Cornwall Hospitals NHS Trust with the necessary
      information on the recognition, management and treatment of outbreaks of Norovirus
      and should be read in conjunction with the Outbreak Policy.

      This version supersedes any previous versions of this document.

3. Scope
This document applies to all staff including bank and agency staff working within the
Royal Cornwall Hospitals NHS Trust.

      3.1. Signs and Symptoms of Norovirus

           3.1.1.      The average incubation period for Norovirus associated gastro-
           enteritis is 12-48 hours.

           3.1.2.     The illness is characterized by a sudden acute onset of:

            Vomiting (This is the predominant symptom, often projectile, and is seen in
           50% of cases, however, clusters can occur where vomiting is infrequent or
           absent altogether).
            Watery diarrhoea and abdominal cramps
            Nausea

           3.1.3.      In addition headache, myalgia, fever and malaise are common. Some
           or all of the above symptoms may be present.

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3.1.4.     Symptoms last between one and three days and recovery is usually
           rapid.

           3.1.5.    Dehydration is the most common complication and patients may
           require replacement fluids.

      3.2. Transmission
           3.2.1.    Noroviruses are highly contagious. It is estimated that around
           30,000,000 (30 million) viral particles are released during one vomiting incident.
           However, it only takes around 100 of these particles to cause illness.
           Noroviruses are transmitted primarily through the faecal–oral route either by
           person to person spread or via contaminated food or water. In addition
           Noroviruses can be spread via aerosol dissemination of infected particles
           following vomiting.

           3.2.2.   Transmission can also occur through hand transfer of the virus to the
           oral mucosa following contact with environmental surfaces, fomites and
           equipment which have been contaminated with either faeces or vomit.
           Norovirus can survive for up to 12 days on some surfaces.

      3.3. Diagnosis
           3.3.1.    Norovirus may be suspected clinically in patients and staff with a
           history of vomiting of sudden onset followed by diarrhoea. During an outbreak
           several people are commonly affected over a short space of time and cases
           with typical features may be ascribed to Norovirus infection without further
           testing.

           3.3.2.   Confirmation of Norovirus infection depends on a PCR test performed
           on faecal samples. This is useful in confirming the nature of an outbreak early
           on. Once Norovirus is identified on a ward, further testing will only be
           performed in order to determine whether Norovirus shedding is occurring in
           cases of persistent diarrhoea or whether the virus has spread throughout the
           ward. Norovirus testing may be performed in order to identify atypical or outlying
           cases. The test will only be performed after discussion with the Infection Control
           team or Microbiologists. Testing is available daily with a result available the
           same day for samples arriving at the laboratory before 09.30hrs.

           3.3.3.     When an outbreak is suspected, it is imperative to institute infection
           control measures immediately without waiting for virological confirmation from
           stool testing.

      3.4. Treatment
           3.4.1.    There is no effective treatment for Noroviruses. It is a self-limiting
           illness which will cease within a few days. It is important to ensure prompt fluid
           replacement to prevent dehydration and its complications.

           3.4.2.     Anti-emetics or anti-motility agents must not be prescribed.

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
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4. Definitions / Glossary
      4.1. Norovirus – a highly contagious small round structured virus capable of
      causing symptoms of diarrhoea and/or vomiting.

      4.2. Outbreak - An incident in which two or more people experiencing a similar
      illness are linked in time/place; or a greater than expected rate of infection compared
      with the usual background rate for the place and time where the outbreak has
      occurred.

5. Ownership and Responsibilities
      5.1. Role of General Managers/Clinical Leads
      Divisional Managers/ clinical leads must ensure that resources are available for
      health care workers to undertake effective standard and isolation precautions.

      5.2. Role of Wards Sisters/Charge Nurses and Departmental
      Managers
      Are responsible for ensuring that staff are aware of this guidance and that the
      guidance is implemented.

      They are responsible for ensuring that the toolbox talk on Norovirus is cascaded
      to all staff during the first 2 weeks of November. Any member of staff who is
      absent during this period should receive an update as soon as possible on their
      return.

      They are responsible for ensuring that Occupational Health have been informed
      of any staff with symptoms of Diarrhoea and/or vomiting during outbreaks of
      Norovirus.

      5.3. Role of Individual Staff
      All staff have a clinical and ethical responsibility to carry out effective Infection
      prevention and control procedures and to act in a way, which minimises risk to
      the patient. All staff are responsible for attending a tool box talk during the first
      two weeks of November if they work in a clinical area. Any member of staff who
      is absent during this period should receive an update as soon as possible on
      their return.

      5.4. Role of Ward Staff – action card number 14
       Ward staff are required to be vigilant for all cases of diarrhoea and report any cases
      of suspected infectious diarrhoea to the IPAC team or Site Co-ordinators out of
      hours.

       Ward staff are responsible for ensuring stool specimens are collected and
      submitted promptly and that the completion of the relevant documentation has been
      carried out ie stool charts.

       Ward staff working on those wards that are affected with Norovirus, are responsible
      for reporting and recording details of patients with suspected Norovirus and providing
      an up to date list on a daily basis to the IPAC team.

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5.5. Infection Prevention and Control (IPAC) Team – action card
      number 9
       The IPAC team are responsible for providing appropriate advice on the
      management of patients diagnosed as having or suspected as having Norovirus. The
      IPAC team are responsible for the coordination of specimen collection and testing
      (see below) and dealing with the infection control aspects of results.

       The IPAC team are responsible for reviewing and updating this policy.

      5.6. Role of Microbiology Department
      The laboratory will provide a daily same-day testing service for faecal samples
      received by 14.30pm weekdays and 09.30am weekends and sanctioned by the
      IPAC/microbiologists/site coordinators.

      5.7. Role of Occupational Health Department
      The Occupational Health Department are responsible for collating information on
      staff with symptoms of diarrhoea and/or vomiting and for informing the IPAC
      team of areas with increased incidence of symptoms.

      5.8. Role of the Hospital Infection and Control Committee
      The Hospital Infection Prevention and Control Committee is responsible for
      approving this policy.

      5.9. Role of the Outbreak Control Group
      The outbreak control group is responsible for monitoring compliance with this
      policy via the outbreak meetings.

      5.10. Role of the Clinical Site Co-ordinators – Action card
      The Clinical site co-ordinators are responsible for ensuring suspected cases of
      Norovirus are isolated in accordance with this policy and to ensure there is no
      inappropriate movement of patients unless there is an urgent clinical need. They
      are responsible for co-ordinating cleaning plan when areas are due to re-open.

6. Standards and Practice
      6.1. Ward Management
           6.1.1.     Isolation
                 6.1.1.1.    Any patient admitted with symptoms suggestive of Norovirus
                 must be triaged in the Emergency Department and fast tracked to the
                 isolation ward. Where the patient condition does not allow admission to
                 the isolation ward, they must be admitted to a side room preferably on a
                 base ward to avoid admitting to MAU. The Infection Prevention and
                 Control Team should be informed at the earliest opportunity of the
                 patient’s admission.

                  6.1.1.2.   The priority is to ensure that patient care is not compromised
                  and at the same time prevent the spread of the virus to other susceptible
                  patients and prevent a major hospital outbreak.

                  6.1.1.3.    Doors to bays/ rooms MUST remain closed.
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6.1.1.4.      Symptomatic patients must have dedicated commodes/toilet
                  facilities.

                  6.1.1.5.    Symptomatic patients must have dedicated equipment e.g.
                  monitoring equipment. Patient equipment must be cleaned and disinfected
                  with a chlorine based disinfectant between each patient use.

                  6.1.1.6.  Patients on an affected ward should be provided with a leaflet
                  with measures to reduce the risk of acquiring Norovirus (RCHT1502 V2).

                  6.1.1.7.     The allocation of a single room will generally take precedence
                  over all other “alert” organisms with the exception of
                  suspected/confirmed pulmonary tuberculosis, suspected/confirmed
                  symptomatic Clostridium difficile, suspected/confirmed bacterial meningitis
                  (for the first 24 hours of antibiotic therapy), chicken pox, Typhoid, CPE.

                  6.1.1.8.   If staff are unsure as to whether a patient already in a single
                  room can be de-isolated, the Infection Prevention and Control Team must
                  be contacted (out of hours, Microbiologist via switchboard).

                  6.1.1.9.    A poster (available in ward norovirus pack) must be displayed
                  at the entrance of the ward advising that there is an outbreak of diarrhoea
                  and vomiting.

           6.1.2.      Ward Closure

                  6.1.2.1.    Ward closure will be made following risk assessment of the
                  area where the diarrhoea has occurred. When 2 or more bays are
                  affected, actions are required to ensure that the unaffected bays in a ward
                  can remain open, including: revised staffing to enable separate staffing of
                  affected and unaffected areas, confirming that the ward design permits
                  effective isolation of affected from unaffected areas, and availability of
                  designated toilet facilities. Full ward closure should be undertaken if it is
                  not possible to implement the identified additional infection prevention
                  actions, and the ward must be closed until those required measures have
                  been achieved. The open/closed status of any affected ward must be
                  reviewed and decided by the Outbreak Control Group.

                  6.1.2.2.    If a patient develops symptoms of suspected Norovirus and
                  they are in a bay with others, the patient should be isolated in a side room
                  on that ward and the whole bay must be closed immediately in an attempt
                  to contain the spread of infection from both affected and exposed patients.
                  This decision should be made:

                   Within hours by the Ward Sister/Matron and Infection Prevention and
                  Control Team
                   Out of hours by the Ward Sister/Matron and Site Coordinator

                  6.1.2.3.    An urgent senior clinical assessment must be completed to
                  determine if the bay closure should remain closed. This should be carried
                  out by the following:

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
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 Within hours - the Infection Prevention and Control team, Matron/ward
                 sister and Consultant/Medical team
                  Out of hours - the Site Coordinator, On-Call Microbiologist and On-
                 Call registrar/Consultant.

                 6.1.2.4.    There must be no further admissions to the closed bay/ward
                 until advised by the IPAC team.

                 6.1.2.5.  Dedicated nursing staff must be allocated to nurse symptomatic
                 /exposed patients.

     6.2. Personal Protective Equipment (PPE)
          6.2.1.   PPE e.g.: aprons and gloves must be used appropriately (single use
          items) and for each episode of care/treatment/examination on all patients by all
          staff.

           6.2.2.    Long sleeved gowns must be worn by staff who are not specifically
           allocated to care for affected patients but who are called on to assist with the
           care of affected patients plus any visiting personnel required to have patient
           contact. These must be changed for each episode of care.

           6.2.3.     There is currently no evidence to support the wearing of face masks
           for either patients or staff.

     6.3. Hand Hygiene
          6.3.1.   The hands of healthcare staff can provide the vehicle for the
          transmission of Norovirus. It is essential that all staff wash their hands when
          required using the correct washing technique to help reduce the risk of
          transmission.

           6.3.2.   Alcohol gel is not effective against these viruses and therefore hands
           must be washed with soap and water before and after every patient contact and
           contact with potentially infectious equipment, furnishings or other fomites.

           6.3.3.     Gloves do not obviate the need to wash hands.

           6.3.4.   Patients must be provided with the opportunity to wash their hands or
           use hand wipes after each toileting episode and also before each meal.

     6.4. Patient Movement
          6.4.1.      There must be no transfer of patients to other
          departments/wards/hospitals from Norovirus affected wards unless there is an
          urgent clinical need in which case the receiving department must be informed.
          In this situation, the patient must be seen immediately on arrival to the
          department and preferably at the end of a list. Minimal numbers of staff should
          attend the patient. Long sleeved gowns and gloves must be worn. All
          equipment that the patient has come in contact with must be cleaned with a
          chlorine based disinfectant e.g. Actichlor plus. The patient must return directly
          to the ward and must not wait in a waiting area with others.

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
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6.4.2.     In the event of the patient requiring surgery, theatre staff must be
           informed that the patient is from a Norovirus affected ward. The patient must be
           placed last on the list. The patient must go directly to the anaesthetic room and
           must be recovered in theatre. The patient must not be recovered in the
           Recovery area with other patients. Minimal numbers of staff should be in the
           theatre. The theatre, all equipment and anaesthetic room must be cleaned
           thoroughly using a chlorine based disinfectant after the patient has left theatre.
           If the patient is due to have elective surgery and has symptoms of Norovirus it is
           advised not to continue with surgery until symptoms have resolved.

           6.4.3.   The movement of affected patients from one ward to another for
           cohort management is NOT recommended.

           6.4.4.   Patients from Norovirus affected wards must not be discharged to
           Care Home facilities unless they have had the illness and are 72 hours
           symptom free or they have been admitted from a Home with confirmed
           Norovirus. Patients can however be discharged to their own homes.

     6.5. Staff
          6.5.1.      Non-essential staff must not visit the affected bay/ward. Wherever
          practicable/possible procedures i.e. venepuncture, ECG’s should be undertaken
          by ward staff. Where bays only are closed, a team of dedicated staff should be
          allocated to these bays. Staff (nursing, domestic) who are working on affected
          wards must not be moved to work in other parts of the hospital within the shift,
          They can work on other wards if necessary the following day providing 12 hours
          have elapsed, they have showered, wear a clean uniform and feel well. The
          use of Bank and Agency staff is not advised on affected areas. Allied Health
          Professionals (AHP’s) should allocate a nominated individual to affected wards.
          If this is not possible, the affected wards must be visited last and long sleeved
          disposable gowns must be worn.

           6.5.2.    If an AHP, who has been allocated to the affected wards, is working
           on an affected ward when it is re-opened they may continue working on the
           ward if they have already started treatments. If they are off the ward when the
           ward is re-opened they should stay off the ward and staff who are allocated to
           non-affected wards should take over treatments on this particular ward.

           6.5.3.    Wherever possible, medical staff should be allocated to the affected
           wards. If this is not possible, the affected wards must be visited last the
           exception being where emergency treatment is required. Hands must be
           washed with soap and water before and after each patient contact or contact
           with their immediate environment. Aprons and gloves must be worn for each
           patient contact however if medical staff have to visit other wards long sleeved
           disposable gowns must be worn for patient contact.

           6.5.4.      Staff who become symptomatic with diarrhoea and /or vomiting must
           leave the area immediately and must not return to work until 48 hours symptom
           free. They must inform the person in charge of the area to ensure that any toilet
           facilities are terminally cleaned.

           6.5.5.   Staff maybe required to submit a sample of faeces to assist with
           outbreak investigation.
Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
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6.5.6.  Staff should inform Occupational Health of their symptoms. A
           message can be left on the answerphone outside of working hours.

     6.6. Ward Staff
          6.6.1.   An outbreak form (Appendix 3) for symptomatic patients and Staff
          (Appendix 4) must be maintained by the ward team. This will be reviewed daily
          by a member of the Infection Prevention and Control Team.

           6.6.2.     Bristol Stool (Appendix 5) and fluid balance charts must be maintained
           on all affected patients.

           6.6.3.    Ward staff must inform domestic services of the situation and advise
           the use of Antichlor Plus.

           6.6.4.   Water jugs must be kept covered to prevent the water from becoming
           contaminated, washed thoroughly each day in a dish washer, and the water
           changed frequently.

           6.6.5.  Bowls of fruit and open packets of food, i.e. biscuits, must be removed
           as they may become contaminated as a result of aerosol contamination.

           6.6.6.     Eating and drinking in the open ward is not permitted.

           6.6.7.    It is essential that if a ward is affected by Norovirus discharge
           planning is continued to ensure prompt discharge of patients once the ward re-
           opens.

     6.7. Ward Cleaning
     Whilst a bay or ward is closed during an outbreak, the area must be cleaned
     daily with both detergent and chlorine e.g. Actichlor Plus. Frequently used areas
     such as toilet areas should be cleaned at least three times daily and more
     frequently should the need arise. A decision regarding the frequency of cleaning
     must be made by the Outbreak Control Group.

     6.8. Visiting
          6.8.1.    Visiting should be restricted to close family members and friends only
          - preferably the same people visiting for the period of the ward/bay closure.

           6.8.2.     No children to be allowed to visit unless the patient is critically ill.

           6.8.3.    Visitors must not visit if they have had diarrhoea and vomiting. They
           must be 48 hours symptom free before they can visit. They should not visit if
           they have been in contact with anyone with diarrhoea and vomiting until 48
           hours after contact.

           6.8.4.   On entering the ward, visitors must be instructed to wash their hands
           with soap and water.

           6.8.5.   They should visit only the patient they have come to see and not go
           from bed to bed.

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6.8.6.   On leaving the ward, visitors should be instructed to wash their hands
           with soap and water.

           6.8.7.   If a visitor to an affected ward needs to visit a non-affected ward, this
           should be discouraged. If however this is essential then the visit to the affected
           ward should be carried out last.

     6.9. Ward Re-opening
          6.9.1.    Rooms, Bays, or the Ward may be terminally cleaned and reopened
          72 hours after the last symptomatic episode, on the instruction of the IPAC
          team, Infection Control Doctor or Microbiologist (in accordance with the Ward
          Closure Policy). Equipment that cannot be decontaminated must be disposed
          of. Any patients remaining in the bay should be decanted out of the bay to a bed
          within the ward (do not transfer patients to other wards) to facilitate an
          effective terminal clean. If this cannot be achieved at least one bed space
          should be available to facilitate effective cleaning of the bay.

           6.9.2.    The terminal clean must be monitored by either the IPAC team, Site
           Co-ordinator, Ward Sister/Charge Nurse or Matron. Whenever possible,
           following a clean using a detergent solution and completion of the Terminal
           clean sign off form, appendix 7, Hydrogen Peroxide Vapour
           (HPV) must be used.

           6.9.3.   On occasions where it is inappropriate to use HPV i.e. previously
           closed bays unable to be vacated prior to the terminal clean, a Hypochlorite
           based solution i.e. Actichlor should be used.

           6.9.4.    The ward/bay must not be re-opened until approved by nurse in
           charge/ IPAC team or site co-ordinator.

     6.10. Communication
     For the duration of any period of closure the Chief Executive, Executive
     Directors, Divisional Directors, Chief Operating Officer and any other relevant
     personnel will be updated by the Infection Prevention and Control Team on a
     daily basis.

     6.11. Escalation Procedure
     When a bay/ward has been closed with confirmed Norovirus, an outbreak
     control group will be convened by the DIPC. Once convened, the outbreak
     control group will determine the frequency of future meetings.

7. Dissemination and Implementation
This policy will be implemented via the following routes:
     The policy will be included in the Trust’s Document Library.
     The policy will be circulated to all Link Practitioners and Matrons

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8. Monitoring compliance and effectiveness

  Element to be           Ward management of patients with confirmed or suspected
    monitored                                      Norovirus.
      Lead                                     Louise Dickinson
                        Joint DIPC/Consultant Nurse Infection Prevention and Control
                      This will be monitored against the actions specified in section 8
       Tool
                 This will be monitored daily and via any outbreak meetings that are
    Frequency
                                              convened.
    Reporting   Any actions requiring immediate attention will be reported to the
  arrangements  ward sister or nurse in charge at that time. An outbreak report will
                be completed by the DIPC at the end of any outbreak of norovirus
                which will be submitted to the Hospital Infection Prevention and
                Control Committee.
    Acting on   The Hospital Infection Prevention and Control Committee will
recommendations undertake subsequent recommendations and action planning for
   and Lead(s)  any or all deficiencies and recommendations within reasonable
                timeframes

                      Required actions will be identified and completed in a specified
                      timeframe
    Change in         Required changes to practice will be identified and actioned
   practice and       immediately where necessary. A lead member of the team will be
  lessons to be       identified to take each change forward where appropriate. Lessons
      shared          will be shared with all the relevant stakeholders

9. Updating and Review
     This policy will be reviewed within 3 years

10. Equality and Diversity
     10.1.This document complies with the Royal Cornwall Hospitals NHS Trust
     service Equality and Diversity statement which can be found in the 'Equality,
     Diversity & Human Rights Policy' or the Equality and Diversity website.

     10.2. The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information
                                           Outbreaks of Suspected or Confirmed Norovirus
 Document Title
                                           Policy V7.0

 Date Issued/Approved:                     12 November 2018

 Date Valid From:                          December 2018

 Date Valid To:                            December 2021

 Directorate / Department                  Louise Dickinson, Joint DIPC/Consultant Nurse
 responsible (author/owner):               Infection Prevention & Control

 Contact details:                          01872 254969
                                           This policy has been developed to provide a
                                           practical document to equip all healthcare staff at
                                           the Royal Cornwall Hospitals NHS Trust with the
 Brief summary of contents
                                           necessary information on the recognition,
                                           management and treatment of outbreaks of
                                           Norovirus.
 Suggested Keywords:                       None
                                                 RCHT               CFT             KCCG
 Target Audience
                                                  
 Executive Director responsible
                                           Nurse Executive
 for Policy:
 Date revised:                             October 2018
                                           Policy for the Management of outbreaks of
 This document replaces (exact
                                           suspected/confirmed Norovirus V6.0
 title of previous version):

 Approval route (names of
                                           Hospital Infection Prevention & Control Committee
 committees)/consultation:

 Divisional Manager confirming
                                           Louise Dickinson
 approval processes
 Name and Post Title of additional
                                           Not required
 signatories
 Name and Signature of
 Divisional/Directorate                    {Original Copy Signed}
 Governance Lead confirming
 approval by specialty and                 Louise Dickinson
 divisional management meetings

 Signature of Executive Director           {Original Copy Signed}
 giving approval

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
                                            Page 15 of 35
Publication Location (refer to
 Policy on Policies – Approvals            Internet & Intranet          Intranet Only
 and Ratification):
 Document Library Folder/Sub
                                           Clinical / Infection Prevention & Control
 Folder
 Links to key external standards           Regulation 12
                                           Health Protection Agency (2007) Guidance for the
                                           Management of Norovirus Infection in Cruise
                                           Ships. London. HPA

                                           Lopman B. et al (2004) Epidemiology and cost of
                                           nosocomial    gastroenteritis, Avon,    England.
                                           Emerging Infectious Diseases 10 (10) 1827.

                                           Lopman B. et al (2004) Clinical manifestation of
                                           Norovirus gastroenteritis in healthcare settings.
                                           Clinical Infectious Disease. 39 (3) 318- 24
 Related Documents:
                                           Norovirus Working Party (2012) Guidelines for the
                                           management of norovirus outbreaks in acute and
                                           community health and social care settings.

                                           Public Health England (2016) Norovirus Toolkit

                                           Haill CF et al (2012) Compartmentalisation of
                                           wards to cohort symptomatic patients at the
                                           beginning and end of norovirus outbreaks.
                                           Journal of Hospital Infection 82 30-35
 Training Need Identified?                 No

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
                                            Page 16 of 35
Version Control Table

              Version                                                     Changes Made by
   Date                        Summary of Changes
                No                                                       (Name and Job Title)
14.01.10        1.0 New Policy                                           Louise Dickinson
                                                                         Consultant Nurse
                                                                         Infection Prevention
                                                                         and Control
07.11.11         2.0   Formatted into new Policy format. Updated in      Louise Dickinson
                       accordance with new Community wide                Consultant Nurse
                       Norovirus Plan.                                   Infection Prevention
                                                                         and Control
22.05.13         3.0   Revision                                          Louise Dickinson
                                                                         Consultant Nurse
                                                                         Infection Prevention
                                                                         and Control
11.09.13         4.0   Updated following debrief in response to          Louise Dickinson
                       outbreak in 2013. Re-formatted to new policy      Consultant Nurse
                       format.                                           Infection Prevention
                                                                         and Control
                                                                         Louise Dickinson
                         Revised and reformatted. Updated following
                                                                         Consultant Nurse
 07.07.15        5.0     debrief in response to the outbreak in
                                                                         Infection Prevention
                         2014/15.
                                                                         and Control
                         Amendments to section 10 ward closure and       Louise Dickinson
                         subsequent amendments to action cards.          Consultant Nurse
 18.11.16        6.0
                         Introduction of action card for domestics and   Infection Prevention
                         housekeepers.                                   and Control.
                                                                         Jean James
                                                                         CNS
 01.09.17        6.1     Added clarity on cleaning
                                                                         Infection Prevention
                                                                         and Control
                                                                         Louise Dickinson
                         Amendments made to reflect timing of            Consultant Nurse
 26.10.18        7.0
                         specimen to lab. Stool chart updated.           Infection Prevention
                                                                         and Control.

All or part of this document can be released under the Freedom of Information
                                   Act 2000
      This document is to be retained for 10 years from the date of expiry.
              This document is only valid on the day of printing

                             Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
 Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the
               express permission of the author or their Line Manager.

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
                                            Page 17 of 35
Appendix 2. Initial Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to
as policy):
               Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
Directorate and service area:                Is this a new or existing Policy?
Infection Prevention and Control             Existing
Name of individual completing                Telephone: 01872 254969
assessment: Louise Dickinson
1. Policy Aim*           To protect patients, staff and the general public by preventing cross-
                         infection and contamination of the environment.

2. Policy Objectives*      To provide clear infection prevention and control guidance for the
                           management and control of a confirmed or suspected outbreak of
                           transmissible infection. It supplements the guidance provided in the
                           Major outbreak Policy.
3. Policy – intended       To reduce the risk of cross infection and escalation of the outbreak
Outcomes*                  situation.

                           To reduce the number of unnecessary ward closures
4. *How will you           Daily at bed management meetings and arranged outbreak meetings
measure the
outcome?
5. Who is intended to                             All Staff and patients at risk.
benefit from the
policy?

6a Who did you             Workforce       Patients         Local       External      Other
consult with                                                groups      organisations
                           X
                        Please record specific names of groups
b). Please identify the
                        Infection Prevention and Control Steering Group
groups who have
                        Hospital Infection Control Committee
been consulted about
this procedure.
What was the               Policy approved
outcome of the
consultation?

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
                                            Page 18 of 35
7. The Impact

Are there concerns that the policy could have differential impact on:
Equality Strands:     Yes No        Unsure Rationale for Assessment / Existing Evidence
Age                          

Sex (male,                      
female, trans-
gender / gender
reassignment)
Race / Ethnic                   
communities
/groups
Disability -                    
Learning disability,
physical
impairment,
sensory
impairment, mental
health conditions
and some long term
health conditions.
Religion /                      
other beliefs
Marriage and                    
Civil partnership
Pregnancy and                   
maternity
Sexual                       
Orientation,
Bisexual, Gay,
heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
    You have ticked “Yes” in any column above and
    No consultation or evidence of there being consultation- this excludes any policies
      which have been identified as not requiring consultation. or
    Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended.      Yes               No   

9. If you are not recommending a Full Impact assessment please explain why.

None of the equality strands have been identified in the initial impact assessment.

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
                                            Page 19 of 35
Signature of policy developer / lead manager / director      Date of completion and submission

Louise Dickinson                                             12 November 2018
Names and signatures of            1. Louise Dickinson
members carrying out the           2. Human Rights, Equality &
Screening Assessment               Inclusion Lead

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD

This EIA will not be uploaded to the Trust website without the signature of the
Human Rights, Equality & Inclusion Lead.

A summary of the results will be published on the Trust’s web site.

Signed __ Louise Dickinson_____

Date ____12 November 2018___

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
                                            Page 20 of 35
Appendix 3. Escalation Levels

   Level                  Situation                                Actions
   Green               All areas open             No specific actions. Vigilance required
                                                       to patients being admitted with
                                                    diarrhoea and vomiting or exposure
                                                  to, particularly between the months of
                                                              October and April.
                                                  Monitor activity in the community and
                                                      alert admitting areas to any Care
                                                     Homes/Community Hospitals that
                                                               maybe affected.
                                                     Risk assessment to be completed.
                                                    Commence toolbox talks during the
                                                  first 2 weeks of November if norovirus
                                                    has not yet been isolated within the
                                                                   hospital.

   Amber            Norovirus confirmed.                        As above plus:
                   Two bays closed (one                First outbreak meeting to be
                    bay in two ward settings)           convened. Frequency to be
                    norovirus confirmed.           determined by the outbreak control
                              Or                                     group.
                   One ward closed with          All staff to follow actions in their action
                    confirmed norovirus                              cards.
                                                  Restrict movement of patients unless
                                                             urgent clinical need.

    Red             Norovirus confirmed.                      As above plus:
                   MAU 1 or 2 closed                 Daily outbreak meetings to be
                              Or                    convened (invite PHE and KCCG).
                   Two wards closed with
                    confirmed norovirus
   Black             Norovirus confirmed                     As above plus:
                   Both MAU 1&2 closed              Seek advice from Public Health
                              Or                                England.
                   3 or more wards closed          Consider opening the control room
                    with confirmed                 and running as a business continuity
                    norovirus.                                  incident.

Outbreaks of Suspected or Confirmed Norovirus Policy V7.0
                                            Page 21 of 35
Appendix 4. Outbreak Form - Patients
Hospital: ………………………….                                               Ward: ………………………………………                                       Start Date: ………………………………

Time Bay closed: ………………..                                                                                   Closed By: …………………………………..

             Name                      Date of          Bed/Bay        Specimen    Relevant Clinical Details /             Record number of episodes and type of stools daily
        Patient Number                Admission                          sent             Antibiotics
             DOB                                                        (date)                                       Mon        Tue       Wed        Thur        Fri      Sat   Sun

Key: D = Diarrhoea V = Vomit Dclin = diarrhoea ?clinical          LS = Loose Stool      -ve = no symptoms        SR = side room O/N = Over Night Closed = closed to
admissions
Relevant Clinical Details: Con = constipated; Lax = taking prescribed laxatives; Nutrit = receiving nutritional support, eg PEG feeding; Anti = antibiotics prescribed.
Please also include any medical / clinical condition that may cause vomiting or diarrhoea, ie inflammatory bowel disease.

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 22 of 35
Appendix 5. Outbreak Form - Staff
Hospital: ………………………….                                    Ward: ………………………………………                      Start Date: ………………………………

                Name                              Job title                    Symptoms   Start of symptoms      Specimen         End of
                                                                                                              Submission Date   symptoms

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 23 of 35
Appendix 6. Bristol Stool Chart

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 24 of 35
Appendix 7. Terminal Clean Sign-off Form
Ward:                                           Bay or side room:

Section 1-7 to be completed for each bay/room
Section 8-9 to be completed for each Dirty Utility
Section 10 to be completed for each bathroom
Section 11 to be completed for the ward corridor

Mitie Supervisor to complete sign off prior to contacting IPAC or Site Co-Ordinator.

                                                                                                 Yes     No    Yes   No
                                                                                                 Mitie        RCHT
1    Have all curtains been removed ?
2    Have all bedside telephones been cleaned and earpieces changed?
     ( check all phones, the TV wall mounting, TV arms and TV screens in each bay)
3    Are all high levels dust free?
     ( check curtain tracks, bedside lights, top of door frame to the bay/room, window cill,
     tops of cupboards, shelves, clock, Window blind track and vertical slats)
4    Are all low levels dust/stain free?
     ( check skirting board, underside of bed frames, flooring ,any visible pipe work,
     waste bins and radiator. Radiator covers must be removed and Sealant of the
     radiator must be removed from flooring)
5    Are all items of bedside furniture clean?
     All parts of the locker must be unlocked/accessible.
     (tables, chairs, lockers, urinal holders, drip poles, - check all pieces of furniture in
     bay by turning furniture up-side down / taken apart)
6    Have all items that cannot be cleaned been disposed of?

7    If equipment is to be left in a room to be HPV’d -
     Have all re-usable patient devices ie dynamap, been cleaned with detergent and are
     all surfaces dust / stain free ?
8    Is the Dirty Utility clean ?
     (check skirting board, flooring and any visible pipe work are dust/stain free. Radiator
     covers must be removed and Sealant of the radiator must be removed from
     flooring).
     Are all high levels dust / stain free?
     Are all low levels dust / stain free?
9    Are all commodes clean? All commodes must be visibly clean (check by turning
     equipment upside down )

     Is the Macerator stain free ?

10   Is the toilet area clean (including those in bathrooms)?
     (check all toilet and seat surfaces, toilet roll holder, skirting board, flooring and any
     visible pipe work are dust/stain free Radiator covers must be removed and Sealant
     of the radiator must be removed from flooring.)
11   Ward corridor

     Are all high levels dust / stain free?
     Are all low levels dust / stain free?
     ( check skirting board, around base of desks )

     Are the walls free from tape / tack/ dust /stains ?

     Is the flooring dust / stain free?

12   The Sister’s office, Dr’s office, Treatment room, clinical prep room etc are dust free.
     These areas should be kept dust free via the daily cleaning schedule.

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 25 of 35
Mitie staff
Name of person undertaking sign off: ____________________________________

Signature of person undertaking sign off:________________________________

Designation: _________________________________________

Date ___________________________

RCHT staff

Name of person undertaking sign off: ____________________________________

Signature of person undertaking sign off:________________________________

Designation: _________________________________________

Date ___________________________

Terminal Clean Sign off form to be retained by the MItie Domestic Supervisor

Domestic Supervisor to scan the form and email it to the infection prevention and control
GroupWise account.

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 26 of 35
Appendix 8. Norovirus Action Card – ED Staff

                     Level                                                     Action Required

                   Green                       Be alert to any new cases of diarrhoea and/or vomiting.
              All areas open                   Participate in Norovirus toolbox talk
                                               Report any concerns to IPAC team
               Amber                           Question all new admissions to determine if they have had
         Norovirus confirmed.                   symptoms of D&V or in contact with anyone with D&V in the
          Two bays closed                      last 48 hours.
           (one bay in two                     Complete diarrhoea assessment documentation in
           ward settings)                       admission pack and the diarrhoea risk assessment tool for
           Norovirus                            patients with diarrhoea.
           confirmed.                          All new admissions with history of diarrhoea and/or vomiting
                  Or                            or contact with the same within 48 hours to be directed
          One ward closed                      promptly to the isolation ward. If bed not available on the
           with confirmed                       isolation ward isolate in side room in the department until a
           Norovirus                            side room is available on a base ward rather than admit to
                                                MAU.
                                               Ensure posters are displayed in the waiting area and each
                                                cubicle.
                                               Ensure information regarding the patients infectious state is
                                                forwarded to the receiving area prior to transfer.

                  Red                                                             As above
         Norovirus confirmed.
          MAU 1 or 2
            closed
                   Or
          Two wards closed
            with confirmed
            Norovirus
                 Black                                                            As above
          Norovirus confirmed
          Both MAU 1&2
            closed
                   Or
          3 or more wards
            closed with
            confirmed
            Norovirus

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 27 of 35
Appendix 9. Norovirus Action Card – IPAC Team

                  Level                                                        Action Required

                 Green                            Be alert to any new cases of diarrhoea and/or vomiting.
            All areas open                        Carry out spot checks of stool charts on ward visits.

               Amber                              In conjunction with the nurse in charge/Consultant or Senior
       Norovirus confirmed.                        medic determine whether a bay that has been closed on
      Two bays closed (one                        suspicion of Norovirus needs to remain closed.
       bay in two ward settings)                  Initiate outbreak meeting – DIPC or ICD.
       Norovirus confirmed.                       Visit affected areas daily Monday – Friday
                 Or                               Check outbreak form for details of new cases
      One ward closed with                       Review stool charts of symptomatic cases
       confirmed Norovirus                        Co-ordinate Norovirus testing list
                                                  Attend outbreak meeting ensuring all relevant information
                                                   available for discussion
                                                  Report results to the clinical site coordinators and ward staff
                                                   once available as soon as possible
                                                  Circulate outbreak report on a daily basis
                                                  Maintain side room log Monday – Friday
                                                  Liaise with site co-ordinators regarding the re-opening of areas.
                                                  In conjunction with the nurse in charge and the Domestic
                                                   Supervisor formulate a cleaning plan and forward a copy to the
                                                   site co-ordinator and the Domestic Supervisor.
                                                  Complete an outbreak summary for each area once outbreak
                                                   declared over
                                                  Complete outbreak report once outbreak declared over
                                                  Commence weekend on-call to advise on any new areas that
                                                   are affected and co-ordinate the Norovirus testing.

                Red                                                               As above
         Norovirus confirmed.                                          Attend daily outbreak meetings
      MAU 1 or 2 closed                                        Invite PHE and CCG to outbreak meetings
                 Or
      Two wards closed with
       confirmed Norovirus
               Black                                                              As above
        Norovirus confirmed
      Both MAU 1&2 closed
                 Or
      3 or more wards closed
       with confirmed Norovirus

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 28 of 35
Appendix 10. Norovirus Action Card – Medical Staff
               Level                                                       Action Required
               Green                        Be alert to any new cases of diarrhoea and/or vomiting.
          All areas open                    Participate in Norovirus toolbox talk
                                            Report any concerns to IPAC team
           Amber                            Question all new admissions to determine if they have had symptoms of
    Norovirus confirmed.                     D&V or in contact with anyone with D&V in the last 48 hours.
   Two bays closed (one                    In conjunction with:
    bay in two ward                          Within hours - the Infection Prevention and Control team, Matron/ward
    settings) Norovirus                      sister
    confirmed.                               Out of hours - the Site Coordinator, On-Call Microbiologist
             Or                              Review any area that has been closed provisionally to determine if the
   One ward closed with                     area needs to remain closed.
    confirmed Norovirus                     All new admissions with history of diarrhoea and/or vomiting or contact
                                             with the same within 48 hours to be directed promptly to the isolation
                                             ward. If bed not available on the isolation ward isolate on a base ward
                                             rather than admit to MAU.
                                            Do not transfer any patients from the affected ward to other wards within
                                             the Trust unless this is clinically indicated in which case the patient should
                                             be transferred to a side room.
                                            Do not transfer patients to other wards even when the ward has been re-
                                             opened unless clinically indicated.
                                            Where possible allocate dedicated staff to an affected ward.
                                            If not possible then visit affected area last and wear long sleeved gowns
                                             when entering an affected bay.
                                            Wash hands with soap and water on entering and leaving the ward.
                                            Do not eat or drink on a ward that has confirmed/suspected norovirus.
                                            Do not come to work with symptoms of diarrhoea and/or vomiting. Do not
                                             return to work until 48 hours symptom free. Inform Occupational Health of
                                             symptoms.
                                            If you have symptoms of diarrhoea and/or vomiting whilst at work inform
                                             your manager, leave promptly and inform someone which toilet has been
                                             used to ensure this is cleaned appropriately.
                                            Continue discharge planning.
  Red                                                                          As above
  Norovirus confirmed.
   MAU 1 or 2 closed
  Or
   Two wards closed with
     confirmed Norovirus
  Black                                                                        As above
  Norovirus confirmed
   Both MAU 1&2 closed
  Or
   3 or more wards
     closed with confirmed
     Norovirus

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 29 of 35
Appendix 11. Norovirus Action Card – Clinical Site Co-ordinators
               Level                                                 Action Required
               Green                          Be alert to any new cases of diarrhoea and/or vomiting.
          All areas open                      Report concerns to IPAC team/microbiologist.

           Amber                              All new admissions with history of diarrhoea and/or vomiting or
    Norovirus confirmed.                       contact with the same within 48 hours to be directed promptly to
    Two bays closed                           the isolation ward. If bed not available on the isolation ward
     (one bay in two ward                      isolate on a base ward rather than admit to MAU.
     settings) Norovirus                      Liaise with staff on the isolation ward to ensure that a bed can be
     confirmed.                                made available at all times.
             Or                               If a ward contacts the site co-ordinator to inform them of a
    One ward closed with                      possible Norovirus case (out of hours) following risk assessment
     confirmed Norovirus                       with the on-call microbiologist and registrar ensure patient is
                                               isolated on the affected ward and close the bay/ward. Inform
                                               IPAC team at the earliest opportunity.
                                              Do not admit any new admissions to the affected bay/ward.
                                              Do not transfer any patients from the affected ward to other
                                               wards within the Trust unless this is clinically indicated in which
                                               case the patient should be transferred to a side room.
                                              Attend outbreak meetings and undertake any actions requested
                                               by the Outbreak Control Group.
                                              Once advised by IPAC that bay/ward can be re-opened, arrange
                                               for terminal clean of the area, patients will need to be transferred
                                               out of the bay where possible. Check terminal clean using the
                                               Terminal Clean sign off sheet.
                                              Do not transfer patients to other wards even when the ward has
                                               been re-opened unless clinically indicated.
                                              At weekends ensure the IPAC team are notified of any areas that
                                               are closed promptly at 8am.
               Red                                                          As above
       Norovirus confirmed.
       MAU 1 or 2 closed
                Or
       Two wards closed
        with confirmed
        Norovirus
              Black                                                            As above
       Norovirus confirmed
       Both MAU 1&2
        closed
                Or
       3 or more wards
        closed with
        confirmed Norovirus

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 30 of 35
Appendix 12. Norovirus Action Card – Support Staff (Porters, Supplies,
etc.)

                   Level                                                       Action Required

                Green                              Continue normal ward visits
           All areas open
                Amber                              Do not enter the ward unless absolutely necessary.
        Norovirus confirmed.                       Contact the ward before visiting to ask them to meet you at the
       Two bays closed (one                        door.
        bay in two ward settings)                  If entry to the ward is required wash hands with soap and
        Norovirus confirmed.                        water on entering and leaving the ward.
                  Or                               Do not come to work with symptoms of diarrhoea and/or
       One ward closed with                        vomiting. Do not return to work until 48 hours symptom free.
        confirmed Norovirus                        If you have symptoms of diarrhoea and/or vomiting whilst at
                                                    work inform your manager, leave promptly and inform
                                                    someone which toilet has been used to ensure this is cleaned
                                                    appropriately.
                                                   Inform the Occupational Health of symptoms (ansaphone at
                                                    weekends and evenings)
                 Red                                                           As above
          Norovirus confirmed.
         MAU 1 or 2 closed
                  Or
         Two wards closed
           with confirmed
           Norovirus
                Black                                                             As above
         Norovirus confirmed
         Both MAU 1&2
           closed
                  Or
         3 or more wards
           closed with
           confirmed Norovirus

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 31 of 35
Appendix 13. Norovirus Action Card – Therapies Staff/Pharmacists

                  Level                                                        Action Required

               Green                              Participate in Norovirus toolbox talk.
          All areas open
               Amber                              Where possible allocate dedicated staff to an affected ward.
       Norovirus confirmed.                       If not possible then visit affected area last and wear long
      Two bays closed (one                        sleeved gowns when entering an affected bay.
       bay in two ward settings)                  Wash hands with soap and water on entering and leaving the
       Norovirus confirmed.                        ward.
                 Or                               Do not eat or drink on a ward that has confirmed/suspected
      One ward closed with                        Norovirus.
       confirmed Norovirus                        Do not come to work with symptoms of diarrhoea and/or
                                                   vomiting. Do not return to work until 48 hours symptom free.
                                                  If you have symptoms of diarrhoea and/or vomiting whilst at
                                                   work inform your manager, leave promptly and inform someone
                                                   which toilet has been used to ensure this is cleaned
                                                   appropriately.
                                                  Inform the Occupational Health of symptoms (ansaphone at
                                                   weekends and evenings)
                                                  Continue discharge planning.

                Red                                                               As above
         Norovirus confirmed.
        MAU 1 or 2 closed
                 Or
        Two wards closed
          with confirmed
          Norovirus
               Black                                                              As above
        Norovirus confirmed
        Both MAU 1&2
          closed
                 Or
        3 or more wards
          closed with
          confirmed Norovirus

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 32 of 35
Appendix 14. Norovirus Action Card – Ward Staff
           Level                                             Action Required
           Green                  
                             Be alert to any new cases of diarrhoea and/or vomiting and complete diarrhoea
      All areas open         risk assessment tool.
                          Ensure all patients have a stool chart.
                          Report concerns to IPAC team/site co-ordinators
                          Participate in Norovirus Safety Briefing
        Amber            As above and:
  Norovirus confirmed.  Question all new admissions to determine if they have had symptoms of D&V
   Two bays closed          or in contact with anyone with D&V in the last 48 hours – question within an
    (one bay in two          hour of admission.
    ward settings)        If patients are in a bay and answer yes to the above. Isolate the patient within
    Norovirus                the ward template and close the bay, contact the site co-ordinator and contact
    confirmed.               IPAC team immediately. Leave a message on ansaphone if out of hours.
           Or             If patient has diarrhoea, collect specimen straight away and send to lab.
   One ward closed          Specimens need to be in the lab for 14.30 weekdays 9.30 weekends to ensure
    with confirmed           testing that day.
    Norovirus             Cohorting of the bay is essential to prevent spread to other parts of the ward.
                             Staff to be allocated to this bay only.
                          Ensure long sleeved gowns available for visiting staff or staff who need to
                             assist.
                          Identify bathroom and toilet for the use of patients in the closed bay.
                                                         If Norovirus confirmed:
                          Water jugs must be kept covered to prevent the water from becoming
                             contaminated.
                          Bowls of fruit and open packets of food, i.e. biscuits, must be removed as they
                             may become contaminated as a result of aerosol contamination.
                          Eating and drinking in the open ward is not permitted.
                          Maintain outbreak form with all relevant information.
                          Restrict visiting as per section 6.1.9 of this policy
                          Restrict patient movement unless clinically necessary
                          Continue discharge planning.
                          Once advised by IPAC that bay can be re-opened, arrange for terminal clean
                             of the area, patients will need to be transferred out of the bay where possible.
                          Do not transfer patients to other wards even when the ward has been re-
                             opened unless there is a clinical need to do so.
                          Do not allow staff onto the ward who do not need to be there, meet them at the
                             ward entrance.
                          Ensure patients receive information leaflets on how to reduce the risk of
                             acquiring Norovirus
                          Ensure all visitors receive the Norovirus visiting leaflet
                          Ensure all appropriate signage is displayed.
                          Red                                                     As above
                  Norovirus confirmed.
   MAU 1 or 2 closed
                           Or
   Two wards closed with confirmed Norovirus
                         Black                                                    As above
                  Norovirus confirmed                          Be ready to initiate Business Continuity Plans
   Both MAU 1&2 closed
                         Or
   3 or more wards closed with confirmed Norovirus.

Policy for the management of outbreaks of suspected/confirmed Norovirus V7.0
                                                            Page 33 of 35
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