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Norovirus, Diarrhoea and/or Vomiting Outbreak Policy
NB This policy must be read in conjunction with the Outbreak Management Policy
Policy Number: 322 Supersedes: Previous
organisations
Standards For Healthcare
Services No/s 13
Version No:
Date Of Review:
Reviewer Name:
Completed Action:
Approved by: Date
Approved:
New Review Date:
1.0 August 2011 Tracey Nicholas Prepare for Approval
CPRG 13/11/2013 13/11/2016
Brief Summary of Document:
The purpose of this policy is to provide staff who work in the health care setting / hospital wards of Hywel Dda Health Board with a robust framework of principles and practices to enable them to effectively manage and control any outbreak of Norovirus
To be read in conjunction with:
Isolation/Infectious Diseases Policy/ Standard Infection Precaution Policy/ Personal Protective Equipment Policy
Classification: Clinical Category: Policy Freedom Of Information Status
Open
Authorised by: Caroline Oakley
Job Title Director of Nursing
A signed copy is kept in Corporate Services
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Responsible Officer/Author:
Infection Prevention & Control Team
Job Title:
Lead Infection Prevention and Control Nurse
Contact Details:
Dept Infection Prevention & Control Team
Base Glangwili General Hospital
Tel No 01267 227422 E-mail: Eiry.cartland@wales.nhs.uk
Scope ORGANISATION
WIDE DIRECTORATE
DEPARTMENT ONLY
COUNTY ONLY
Staff Group
Administrative/ Estates
Allied Health Professionals Ancillary Maintenance
Medical & Dental Nursing Scientific & Professional Other
CONSULTATION
Please indicate the name of the individual(s)/group(s) or committee(s) involved in the consultation process and state date agreement obtained.
Individual(s) Infection Control Nurses Date(s) November 2012
Group(s)
County Heads of Nursing, Medical Director, Assistant Director of Nursing Practice
Date(s) January 2013
Committee(s) Infection Prevention & Control Committee
Date(s) November 2012
RATIFYING AUTHORITY (in accordance with the Schedule of Delegation)
KEY
COMMENTS/ POINTS TO NOTE
NAME OF COMMITTEE
A = Approval Required Date Approval
Obtained FR = Final Ratification
Clinical Policy Review Group FR 13/11/12
Date Equality Impact Assessment Undertaken
8th
November 2012
Group completing
Equality impact assessment
Jackie Hooper Tracey Nicholas
Please enter any keywords to be used in the policy search system to
enable staff to locate this policy Isolation Infections, Outbreak Management, Norovirus
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Document Implementation Plan
How Will This Policy Be Implemented?
Utilising normal policy dissemination routes
Who Should Use The Document?
All clinical staff
What (if any) Training/Financial Implications are Associated with this document?
N/a
What are the Action Plan/Timescales for implementing this policy?
Action By Whom By When
Publish approved policy onto intranet Policy Coordinator
June 2013
Advertise Published policy via global email
Policy Coordinator
June2013
Awareness workshops across the Health Board
Infection Prevention and Control Team
July 2013
Promotion via the Infection Prevention and Control Link Nurse System
Infection Prevention and Control Team/Link Nurses
July 2013
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CONTENTS
1. EXECUTIVE SUMMARY ............................................................................................. 6
2. INTRODUCTION ........................................................................................................... 7
3. POLICY AIM ................................................................................................................. 7
4. OUTBREAK RECOGNITION ........................................................................................ 7
5. OUTBREAK REPORTING PROCEDURE .................................................................... 8
6. OUTBREAK MEETING AND MEMBERSHIP ............................................................... 8
6.1 Membership ........................................................................................................... 8
6.2 Outbreak Meeting .................................................................................................. 9 6.2.1 Terms of Reference of the Outbreak Control Team 6.2.2 Agenda for Initial Outbreak Meeting 7. ROLES / RESPONSIBILITIES / FUNCTIONS ............................................................ 10
7.1 Chief Executive .................................................................................................... 10
7.2 Executive Director and Senior Managers ............................................................. 10
7.3 County Management Team ................................................................................. 10
7.4 Senior Nurse - Infection Prevention and Control .................................................. 10
7.5 County Infection Prevention & Control Team ....................................................... 10
7.6 Ward / Unit Managers / Department Leads .......................................................... 10
7.7 All Clinical Staff .................................................................................................... 11
7.8 Ward / Unit Staff - On Suspicion of an Outbreak in a Ward or Clinical Setting: .... 11
8. WARD / UNIT STAFF ON CONFIRMATION OF AN OUTBREAK BY THE IP&CT.11
8.1 Patient Placement ................................................................................................ 11
8.2 Surge Capacity Consideration ............................................................................. 12
8.3 Hand Hygiene .................................................................................................... 122
8.4 Respiratory Hygiene/Cough etiquette .................................................................. 13
8.5 Personal Protective Equipment (PPE) ................................................................. 13
8.6 Management of Care Equipment ......................................................................... 13
8.7 Environmental Cleaning/Decontamination ........................................................... 13 8.7.1 Disinfection 8.7.2 Environmental decontamination during an outbreak 8.7.3 Terminal cleaning following discharge or transfer of patient, or resolution of
symptoms for 48 hours 8.8 Laundry ................................................................................................................ 14
8.9 Prompt clearance of soiling and spillages ............................................................ 15
8.10 Safe Disposal of Waste ...................................................................................... 155
8.11 Information for staff .............................................................................................. 15
8.12 Information for visitors .......................................................................................... 16
9. MANAGEMENT OF SUSPECTED AND CONFIRMED CASES ................................. 17
9.1 The definition of closure ..................................................................................... 177
9.2 Avoidance of admission ....................................................................................... 18
9.3 Clinical treatment of Norovirus ............................................................................. 18
9.3.2 Anti diarrhoeal drugs 9.4 Patient discharge ................................................................................................. 19
10. DEFINING THE END OF AN OUTBREAK ............................................................. 19
11. EVALUATION AND MONITORING ........................................................................ 19
12. REFERENCES ........................................................................................................ 20
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13. APPENDIX 1 DIARRHOEA AND VOMITING OUTBREAK ADVICE FLOWCHART .................................................................................................................... 21
14. APPENDIX 2 NOROVIRUS DECISION TREE ..................................................... 22
15. APPENDIX 3 INFORMATION FOR HEALTH CARE WORKER LEAFLET ......... 23
16. APPENDIX 4 INFORMATION FOR PATIENTS LEAFLET ................................. 25
17. APPENDIX 5 INFORMATION FOR VISITORS LEAFLET .................................. 27
18. APPENDIX 6 INFORMATION FOR RELATIVES/VISITORS WHEN A PATIENT IS IN ISOLATION LEAFLET .............................................................................................. 29
19. APPENDIX 7 HAND HYGIENE INFORMATION LEAFLET ................................ 31
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1. EXECUTIVE SUMMARY
An outbreak of infection is generally deemed to have occurred when multiple individuals become infected with the same organism within a healthcare setting. Suspicion of an outbreak includes the occurrence of two or more cases linked in time or place with symptoms of nausea, diarrhoea and/or vomiting
Suspected Norovirus outbreaks must be reported immediately to: a. County IP&CT (Consultant microbiologist out of hours). b. County Management Team to include the County Head of Nursing/ County
General Manager/County Assistant General Manager/Acute Service Nurse Manager/Senior Nurse/Bed Manager
c. Clinical Team responsible for affected area d. Hospital Director for Clinical Care
On closure of the ward the County IP&CT will call an outbreak meeting as soon as possible which will be then convened daily as a minimum during the course of the outbreak.
Ward/Departmental managers are responsible for completing an IR1 on the electronic datix form in relation to the outbreak incident.
The isolation of cases within single rooms and bays as opposed to the early closure of complete wards allows flexibility of response and the early terminal cleaning and re-opening of affected sub-ward areas. Only when there is evidence of a failure of containment within all available single-occupancy rooms and bays must whole ward closure be considered.
Hand hygiene is considered to be the single most important practice in reducing the transmission of infectious agents including Norovirus, Good hand hygiene is essential during outbreaks.
Respiratory hygiene and cough etiquette is designed to contain respiratory secretions caused by excessive vomiting which can generate aerosols.
Use gloves and apron to prevent personal contamination with faeces or vomit.
The use of shared equipment must be avoided wherever possible through the use of disposables and reusable equipment dedicated for single patient use for the duration of the outbreak
Routine environmental cleaning in accordance with current national & local standards and specifications must be enhanced during an outbreak of norovirus. Key control measures include increased frequency of cleaning, environmental disinfection with Chlorine Dioxide (Tristel) and prompt clearance of soiling caused by vomit or faeces.
For all in-patient areas all linen must be processed as infected linen (please refer to Management of Linen policy) during the Outbreak.
During an outbreak all waste must be placed into orange infected waste bags for disposal.
The vomit and faeces of a symptomatic norovirus patient are highly infectious. To prevent exposure to the virus and minimise the likelihood of transmission, environmental contamination with vomit and faeces must be cleared immediately whilst using appropriate PPE.
Ensure all staff are aware of the norovirus situation and how norovirus is transmitted and that all staff are aware of the work exclusion policy and the need to go off duty at first symptoms.
Staff with symptoms to remain off duty until 48 hours symptom free.
The visitor who has norovirus is a transmission risk and the visitor who does not have norovirus is at risk of contracting it during a visit. The first is obvious infection
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prevention and control hazard but the second is usually not, although there are exceptions (e.g. children who may introduce it to their school). Restrictions on visiting (other than by symptomatic persons) are mainly intended to assist ward staff in outbreak control by reducing the distractions caused by having to attend to visitors.
If a clinical area or unit has both closed and non-closed areas within it, the non-closed areas will remain open to admissions but a risk assessment must be made as to whether patient transfers from the non-closed areas to other clinical areas must be delayed until the risk of the outbreak emerging within the non-closed area is sufficiently low.
Closure refers to the restriction of incoming and outgoing personnel, equipment, materials (including patient notes) to an unavoidable minimum. The fewer times that the portal of a closed area is crossed, the less is the risk of transmission of virus and further spread to other areas
The ward/unit is not to be reopened until all affected patients are 48 hours symptom free and terminal cleaning has been completed. The Infection Prevention and Control Team (IPCT) shall then declare the Outbreak over.
2. INTRODUCTION
This policy is based on a principle of minimising the disruption to services and maximising the ability of Hywel Dda Health Board to deliver appropriate care to patients safely and effectively. This policy advocates an escalatory system of isolation using single rooms and cohort nursing prior to complete ward closure without compromising patient care.
3. POLICY AIM
The general public and staff have a right to expect any potential hazards in a healthcare environment to be adequately controlled. All staff must possess an appropriate awareness of their role in the prevention and control of infection in their area of work. Not only is this part of their professional duty of care to the patients with whom they are involved, but it is also their responsibility to themselves, to other patients and members of staff under the Health & Safety at Work Act (1974). This policy provides a framework for the reporting, investigation and control of outbreaks within in-patient areas of Hywel Dda Health Board and to assist staff in the safe management and control of any outbreak of infection. The main aims of this policy are: -
To ensure staff are able to appropriately identify a Norovirus outbreak situation and implement appropriate infection prevention and control measures / restrictions.
To ensure all relevant parties are informed of the Norovirus outbreak situation and have a clear understanding of their role and duties in the outbreak situation.
To manage and control the spread of infection.
To quickly identify the source, method of spread and causative organisms responsible for the outbreak.
To disseminate information concerning the Norovirus outbreak efficiently.
4. OUTBREAK RECOGNITION
An outbreak of infection is generally deemed to have occurred when multiple individuals become infected with the same organism within a healthcare setting. It is the responsibility of the Infection Prevention & Control Team (IP&CT) to define an outbreak and risk assess
icion of an outbreak includes the occurrence of two or more cases linked in time or place with symptoms of nausea, diarrhoea and/or vomiting.
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5. OUTBREAK REPORTING PROCEDURE
Suspected Norovirus outbreaks must be reported immediately to:
County IP&CT.
County Management Team to include the County Head of Nursing/ County General Manager/County Assistant General Manager/Acute Service Nurse Manager/ Senior Nurse/ Bed Manager
Clinical Team/Staff responsible for affected area
Hospital Director for Clinical Care
Support Services Out of Hours suspected outbreaks must be reported to;
The Consultant microbiologist on call
The Night Nurse Practitioner/Site Manager Please refer to Appendix 1 Diarrhoea and Vomiting Outbreak Advice Flowchart and Appendix 2 Norovirus Tree for advice regarding patient management. Once the IP&CT team have confirmed an outbreak then a Serious Incident Form needs to be completed by the Acute Service Nurse Manager/Assistant General Manger and the County Infection Prevention & Control Nurse (IPCN). This needs to be submitted to the County Quality Manager who will liaise with the Executive Director on call to obtain signatory. If the IP&CT do not deem the situation as an outbreak, then the IP&CT will inform ward / unit staff involved in making the initial referral of a suspected outbreak situation and the reason why it is not deemed an outbreak.
6. OUTBREAK MEETING AND MEMBERSHIP
On closure of the ward the County IP&CT will call an outbreak meeting as soon as possible which will then be convened daily as a minimum throughout the outbreak. An Outbreak Control Team (OCT) meeting will be convened at the earliest opportunity. The extent of the membership of this group will depend on the extent / severity of the outbreak. The Acute Service Nurse Manager/General Manger will be responsible for chairing and organising the meeting and also ensure dissemination of the outbreak minutes to all managers so that all departments are aware of the outbreak situation. Due to potential implications of bed flow with closed wards then it may be appropriate at times for the daily Bed Management Meeting and OCT Meeting to be amalgamated especially as membership of OCT and bed management will overlap.
6.1 Membership:
Nurse in charge of ward or a representative.
Senior nurse / senior manager of outbreak area.
County General Management Team
County IP&CT.
Lead Clinician of outbreak area.
Hotel Services Manager / Deputy.
Bed manager.
Acute Service Nurse Manager.
Occupational Health Doctor / Nurse.
Communication / Media / press officer.
Secretarial support minutes / photocopying etc.
Clinical support Services NB. Other members of staff may be included in the meetings as necessary e.g.
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o County Medical Lead o Consultant in Communicable Disease Control (CDCC). o HSDU manager o Laundry manager o Ambulance / transport representative o Estates manager o Supplies manager o Pharmacy manager.
6.2 Outbreak Meeting The Terms of Reference of the outbreak meeting will be complied with. A member of the IP&CT will take responsibility for taking minutes of the meeting and the Acute Service Nurse Manager /deputy will then agree the minutes and cascade them appropriately. The Acute Service Nurse Manager / deputy will take responsibility for chairing the meetings and ensuring all senior staff are kept informed of meetings i.e. Chief Executive, Director of Nursing and Midwifery. It is the responsibility of the Consultant Microbiologist / Senior Nurse IP&C to update the CCDC as appropriate.
6.2.1 Terms of Reference of the Outbreak Control Team
To be advised by the IP & C Nurse and consultant Microbiologist on the likely source and cause of the outbreak.
To monitor the effectiveness of infection prevention & control measures.
To facilitate the optimal clinical care of patients.
To receive information relating to the outbreak / incident and the results of epidemiological and microbiological investigations including data collection and analysis, and to identify actions that may reduce likelihood of future outbreaks.
Decide the need for outside help and expertise.
To manage the communication between relevant agencies and those with a legitimate interest in the outbreak, including patients and their families.
To define the end of the outbreak.
To evaluate the lessons learned and prepare a report / recommendations of the outbreak for the Infection Prevention & Control Committee and the Health Board.
To provide clear guidelines for communication with patients, relatives, staff and the general public.
Ensure that individuals with assigned individual responsibilities within the outbreak policy are executing their roles.
6.2.2 Agenda for Initial Outbreak Meeting The initial agenda for the first outbreak meeting will include:
The outbreak policy and individual actions / responsibilities.
Initial assessment of the outbreak.
Case definition.
Reporting mechanisms.
Management / investigation of outbreak.
Control measures and effectiveness.
Communication channels.
Frequency of Outbreak Meetings.
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7. ROLES / RESPONSIBILITIES / FUNCTIONS
It is important that the following key staff understand their individual roles in the outbreak situation in order to effectively manage and control the outbreak situation: - 7.1 Chief Executive The Chief Executive has ultimate responsibility for infection prevention and control within Hywel Dda Health Board. This responsibility is delegated to the Director of Nursing and Midwifery who will inform the Chief Executive immediately on being informed of the outbreak situation by the Infection Prevention & Control Team. 7.2 Executive Director and Senior Managers The Director of Nursing and Midwifery has delegated responsibility for infection prevention and control in the Health Board and along with senior managers must be familiar with the outbreak policy and support the implementation of the policy throughout the organisation. In the event of an outbreak the Executive Director of Nursing and Midwifery and Senior Managers must comply with their individual responsibilities as laid out in the Hywel Dda
The Executive on call will inform the Welsh Government using the Serious Incident reporting procedure. 7.3 County Management Team The County Management Team is responsible for regular communication and update to the Executive Director on call and to the communication/media department on the outbreak situation and in the absence of the Consultant Microbiologist liaise with the Consultant in Communucable Disease Control (CCDC) as appropriate. 7.4 Senior Nurse - Infection Prevention and Control Operational responsibility for infection prevention and control within the Health Board lies with the Senior Nurse Infection Prevention & Control who is responsible for supporting the County IP&CTs during the outbreak of infection and ensuring that the outbreak policy is complied with. The Senior Nurse of IP&C is responsible for ensuring mandatory training includes education on outbreak management and control. The Senior Nurse of IP&C is responsible for regular communication and update to the Director of Nursing and Midwifery and the communication / media department on the outbreak situation and in the absence of the consultant microbiologist liaise with the CCDC as appropriate. 7.5 County Infection Prevention & Control Team The County IP&CT will liaise with the outbreak area(s) and assess the control of infection and assess all control measures in place and revise as necessary. The County IP&CT will assess the scale of the outbreak & circulate situation reports daily. This assessment will inform managers of the possible duration and implication on hospital services / activities of the outbreak as well as any additional resources / manpower required for the outbreak area. All updated information must be communicated and agreed at the outbreak control team meeting prior to circulation within the County/Health Board. 7.6 Ward / Unit Managers / Department Leads Ensure all staff are familiar with the outbreak policy and control measures and ensure the policy is complied with. The ward / unit managers / department leads are responsible for ensuring any deficits in resources such as medical and surgical supplies are promptly acted upon. They are also responsible for ensuring non-essential staff and visitors are excluded for the outbreak area and that there is appropriate staffing of the outbreak area (inclusive of staff movement restrictions).
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7.7 All Clinical Staff All health care workers are required to be familiar with the outbreak policy and comply with its contents and are responsible for informing the IP&CT and their manager immediately of any situation whereby an outbreak is suspected.
7.8 Ward / Unit Staff - On Suspicion of an Outbreak in a Ward or Clinical Setting: Inform County Management Team to include the County Head of Nursing/ Acute Service Nurse Manager/ General Manager/Senior Nurse/ Hotel Services Supervisor of suspected outbreak. Inform the County IP&C Nurse or the on-call microbiologist out of hours. Inform bed manager of suspected outbreak and possible bed flow restrictions in the outbreak area i.e. partial or full closure of beds and restricted transfers / discharges.
Ward/Departmental managers are responsible for completing an IR1 on the electronic Datix form in relation to the outbreak incident. NB a risk assessment must be taken on all staff who are working in the affected area to identify those that may have to be excluded from working in the identified area e.g. pregnant members of staff, immunosuppressed or any other issues that may need to be considered.
8. WARD / UNIT STAFF ON CONFIRMATION OF AN OUTBREAK BY THE IP&CT:
On confirmation of an outbreak the following Standard Infection Control Precautions an appropriately placed outbreak / ward closure
posters at entrance to ward. The following instructions must be implemented;
8.1 Patient Placement The isolation of cases within single rooms and bays as opposed to the early closure of complete wards allows flexibility of response and the early terminal cleaning and re-opening of affected sub-ward areas. Only when there is evidence of a failure of containment within all available single-occupancy rooms and bays must whole ward closure be considered. If a patient can be safely discharged home, they must be provided with appropriate patient information to enable their clinical well-being and to minimize the risk of spread within the household. Close affected bay(s) to admissions and transfers. Healthcare Staff must;
Keep doors to single-occupancy room(s) and bay(s) closed
Place signage on the door(s) informing all visitors of the closed status and restricting visits to essential staff and essential social visitors only
Place patients within the ward for the optimal safety of all patients a. Single-occupancy room nursing. This must be carried out according to local IPC policies with reference to norovirus control measures. b. Single cases without available single-occupancy room provision. When single-occupancy rooms are not available, a symptomatic patient must be nursed wherever they are at the time they become symptomatic. Other patients in the immediate vicinity of a symptomatic case are considered as exposed contacts. If the patient is in a bay, then that bay must be closed and all patients in it must be managed as potential cases.
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c. Multiple cases in excess of available single-occupancy room provision. Those cases who cannot be placed in single-occupancy rooms must be cohort nursed in bays. Sometimes there may be individual cases scattered through multiple bays with a larger number of asymptomatic exposed patients in adjacent beds. In such situations, each bay containing a case must be closed and managed as a separate IPC unit. d. Open plan wards. The presence of even a single case on an open plan ward can be problematic. Such wards have no physical barriers between patients and additional attention needs to be given to the distance between beds for optimal prevention of transmission of infection. Also, attention will need to be given to the requirements of single sex accommodation. In such circumstances, there may be no alternative to whole ward closure. However, local solutions must be sought whereby a degree of physical segregation may be made possible. e. Norovirus isolation wards. The creation of short term norovirus isolation wards is not recommended because, unless these wards are part of the routine configuration of the hospital, there may be an unacceptable safety risk to patients as a result of suboptimal management of their other medical conditions. The routine transfer of patients into an isolation ward does not prevent (or even perhaps reduce) the continuing outbreak on the original wards. Also, norovirus illness is of short duration. There may however, be a role for such a ward in hospitals experiencing prolonged outbreaks but careful selection of patients will be required in order to avoid compromising patient safety. f. Decant Wards. If two or more wards are affected by a norovirus outbreak, in the later stages of the outbreak there may be value in moving all infected patients and recovered patients to one ward to allow earlier cleaning and re-opening of an empty ward. g. Multiple Ward closures. Organisations must recognise the risk of multiple wards being affected by norovirus outbreaks and they must consider, during their preparedness or winter pressures planning, the impact of such a situation on their overall activity. NB In the event of a bed crisis any decision to admit to an affected ward must be discussed between the Infection Prevention and Control Team, the Site Manager and the Nurse in charge of the ward.
8.2 Surge Capacity Consideration Acute Service Nurse Manager and the Site Manager will discuss any potential areas for surge capacity to accommodate emergency activity continuation of service provision.
8.3 Hand Hygiene Hand hygiene is considered to be the single most important practice in reducing the transmission of infectious agents including Norovirus, Good hand hygiene is essential during outbreaks. All staff and patients must;
Use liquid soap and warm water as per WHO 5 moments for Hand Hygiene
Encourage and assist patients with hand hygiene especially at meal times and toileting.
Alcohol based hand rubs (ABHRs) must be used for hand hygiene and must be available to staff as near to the point of care as possible. If hands are visibly dirty or soiled and/or when exposure to gastro-intestinal infection e.g. norovirus, is suspected/proven, ABHR must not be used alone and hands must be washed first with non-antimicrobial liquid soap and water.
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8.4 Respiratory Hygiene/Cough etiquette Respiratory hygiene and cough etiquette is designed to contain respiratory secretions caused by excessive vomiting which can generate aerosols:
cover the nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose
dispose of all used tissues promptly into an orange waste bin
wash hands with liquid soap and warm water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions; and
keep contaminated hands away from the mucous membranes of the eyes and nose Staff must promote respiratory hygiene and cough etiquette to all individuals and help those who need assistance with containment of respiratory secretions e.g. those who are immobile will need a receptacle (e.g. plastic bag) readily at hand for the prompt disposal of used tissues and offered hand hygiene facilities.
8.5 Personal Protective Equipment (PPE) Use gloves and apron to prevent personal contamination with faeces or vomit. Consider use of face protection with a mask only if there is a risk of droplets or aerosols. Hand hygiene must be performed on removal of any personal protective equipment.
8.6 Management of Care Equipment The use of shared equipment must be avoided wherever possible through the use of disposables and reusable equipment dedicated for single patient use for the duration of the outbreak. Decontaminate all other equipment immediately after use.
8.7 Environmental Cleaning/Decontamination A clean and safe environment is essential for effective Infection Prevention and Control. Routine environmental cleaning in accordance with current national & local standards and specifications must be enhanced during an outbreak of norovirus. Key control measures include increased frequency of cleaning, environmental disinfection with Chlorine Dioxide (Tristel) and prompt clearance of soiling caused by vomit or faeces. Remove exposed foods, e.g. fruit bowls, and prohibit eating and drinking by staff within clinical areas.
8.7.1 Disinfection Effective cleaning and removal of organic soiling prior to disinfection is essential to maximise the effectiveness of surface disinfectants. Disinfection must be carried out with a
guidance with regards to preparation, usage, contact times, storage and disposal of unused solution. Staff must wear appropriate protective clothing and follow standard infection control precautions. It is essential that appropriate training of staff occurs and they have the knowledge to handle and use these products safely.
8.7.2 Environmental decontamination during an outbreak Cleaning staff and other staff who undertake cleaning tasks must follow standard infection prevention & control precautions and wear appropriate personal protective equipment (PPE) including disposable gloves and apron
Increase frequency of cleaning using dedicated domestic staff where possible and avoiding transfer of domestic staff to other areas
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Clean from unaffected to affected areas, and within affected areas from least likely-contaminated areas to most highly contaminated areas
Use disposable cleaning materials including mops and cloths
Dedicate reusable cleaning equipment to affected areas and thoroughly decontaminate between uses e.g. mop handles and buckets
After cleaning with detergent, disinfect with Chlorine Dioxide (Tristel).
Pay particular attention to frequently touched surfaces such as bed tables, door handles and taps
The frequency of cleaning and disinfection of toilet facilities must also be increased including flush handles, toilet seats, taps, light switches and door handles
National and local colour coding for cleaning equipment must be adhered to, in order to avoid cross contamination
8.7.3 Terminal cleaning following discharge or transfer of patient, or resolution of symptoms for 48 hours
This can take place in the presence of recovered asymptomatic patients although it is preferable to empty a clinical area of patients beforehand. The principles of terminal cleaning cover the disposal of materials where possible, the removal of curtains, the rigour of cleaning, the disinfection of equipment and surfaces and the precise order in which individual tasks are carried out as follows:
1. Discard unused disposable patient-care items 2. If items cannot be appropriately cleaned, consider discarding these items 3. Remove window and privacy curtains avoiding unnecessary agitation and send for
laundering 4. Remove bed linen and unused linen and send for laundering
6. Thoroughly clean all surfaces with a neutral detergent or consider the use of ultra
heated dry steam vapour cleaning 7. Steam cleaning of upholstered furniture and bed mattresses present in rooms upon
patient discharge is suggested 8. After cleaning, disinfect with Chlorine dioxide (Tristel).
The use of ultra heated dry steam vapour cleaning has been found to be effective for removing organic matter and can raise levels of microbiological cleanliness as well as aesthetic cleanliness. In addition: The use of upholstered furniture (unless manufactured with cleanable surfaces which can also be disinfected) and rugs or carpets in patient care areas is to be avoided as these objects are difficult to clean and disinfect effectively. Where they are in use then contamination with vomit or faeces must be cleaned immediately with a suitable
chlorine dioxide will have a bleaching effect and must be avoided unless the fabric or carpet is compatible with chlorine. The use of steam cleaning is recommended. During an outbreak of norovirus the continued use of microfibre mops & cloths is dependent on compatibility with chlorine. Alternative chlorine compatible disposable microfibre or traditional cloths and mops must be used where microfibre materials in general use are not compatible with chlorine. Alternatively, disposable mop heads and cloths may be used during the outbreak.
8.8 Laundry For all in-patient areas all linen must be processed as infected linen (please refer to Management of Linen policy) during the Outbreak.
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Staff must follow standard infection control precautions including the use of PPE when handling used and soiled linen to minimise the risk of personal exposure to the virus.
Linen and other items of laundry must not be held close to the chest to prevent contamination of the uniform (an apron must be worn).
Staff must carefully handle used and soiled linen from symptomatic patients or residents avoiding unnecessary agitation of sheets during bed making to avoid dispersal of the virus into the environment.
If clothing from symptomatic patients or residents is returned to relatives or carers for laundering, they must be given verbal and/or written instruction on how to safely launder the items in the home setting.
Unused linen stored in an affected area e.g. isolation room or cohort bay, must be laundered before use by another patient or resident.
Washing at Ward level should be discouraged. Where this cannot be avoided washing machines must not be overloaded. Any segregation required prior to washing must be carried out before transport to the laundry area, precluding the need for additional handling within the laundry. Staff must never empty bags of linen onto the floor in order to sort the linen into categories as this increases the risk of virus transmission. Heavily-soiled items must also undergo a pre-wash/sluice cycle. To achieve best practice outcomes, an enhanced process must use a washing cycle that has either a thermal disinfection cycle that reaches 71°C for at least three minutes or 65°C for at least ten minutes. All items must go through a drying process (if the item is compatible) and stored in a clean area away from the laundry area and above floor level.
8.9 Prompt clearance of soiling and spillages The vomit and faeces of a symptomatic norovirus patient are highly infectious. To prevent exposure to the virus and minimise the likelihood of transmission, environmental contamination with vomit and faeces must be cleared immediately whilst using appropriate PPE. Prompt decontamination of soiling and spillages;
1. Wear appropriate PPE including disposable gloves and apron and fluid repellent surgical mask if indicated
2. Clear up bulk of spillage using paper towel and discard immediately into dedicated orange waste bag
3. Use fresh paper towel/disposable cloth to clean the area with neutral detergent and hot water. Dry the area
4. Then disinfect the area using a solution of 0.1% sodium hypochlorite (1000ppm available chlorine*)/ Chlorininstructions
5. Dry the area thoroughly 6. Discard all PPE and disposable materials into the dedicated orange waste bag 7. Wash hands with liquid soap and warm water
8.10 Safe Disposal of Waste During an outbreak all waste must be placed into orange infected waste bags for disposal.
8.11 Information for staff
Ensure all staff are aware of the norovirus situation and how norovirus is transmitted (see Appendix 3 Information for Health Care workers leaflet)
Ensure all staff are aware of the work exclusion policy and the need to go off duty at first symptoms
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Allocate staff to duties in either affected or non-affected areas of the ward but not both unless unavoidable (e.g. therapists)
Avoid staff cross cover between affected and non-affected patients (ideally post affected staff to nurse affected patients).
Only essential staff to visit ward, to reduce the risk of infection spreading to other areas, wards and departments
The Infection Prevention and Control Team would recommend that staff take their breaks on the ward. Local arrangements to be made regarding this at the first meeting of the Outbreak Team.
Hotel Services staff working on the affected wards must not provide cover to unaffected ward areas. Hotel Services Supervisor to ensure appropriate cover is provided.
Agency Staff must not work on affected wards. However, Bank Nurses and Nurses from other areas could work on the ward providing:
They remain rostered to the affected ward for the duration of the outbreak.
They have their 2 days off before working on another ward.
They inform the Bank Nurse office.
Staff with symptoms to remain off duty until 48 hours symptom free. A specimen must be submitted, either via the Occupational Health Department, or their GP. Refer staff reporting sick to Occupational Health Department.
Limit the number of personnel accessing the ward; paramedical staff, such as Physiotherapy, Occupational Therapy must only enter the area if therapy is considered essential.
Phlebotomists must not access the area for obtaining routine blood samples.
Staff are advised not to leave ward during outbreaks, liaise with Hotel Services department to arrange portering duties/support wherever possible, e.g. deliver samples to laboratory.
Staff to wear Infection Control scrub suits (contact Hotel Services Supervisor). At end of shift, scrubs to be placed in allocated linen bag; staff are not to wear scrubs outside the clinical environment.
8.12 Information for visitors The visitor who has norovirus is a transmission risk and the visitor who does not have norovirus is at risk of contracting it during a visit. The first is obvious infection prevention and control hazard but the second is usually not, although there are exceptions (e.g. children who may introduce it to their school). Restrictions on visiting (other than by symptomatic persons) are mainly intended to assist ward staff in outbreak control by reducing the distractions caused by having to attend to visitors:
Provide all affected patients and visitors with information on the outbreak and the control measures they must adopt (Appendix 4,5 + 6)
Advise visitors of the personal risk and how they might reduce this risk. Visitors who have vomiting and/or diarrhoea. Visitors who are symptomatic must not visit until at least 48h after the resolution of their symptoms.
Visits by children of school age must be discouraged for the duration of an outbreak because of the risk of sudden symptoms developing without warning in school.
Visitors must be allowed in extenuating circumstances on the decision of the senior manager in the ward or home. Terminally ill patients, children, vulnerable adults and those for whom visiting is an essential part of recovery must be allowed visitors at the discretion of the senior manager. Clinical and social judgment needs to be applied sensitively and compassionately whilst recognising the duty of care for the health and
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well being of all patients, staff and visitors. Those who have travelled a long distance, taken time off work, or in other ways have been significantly inconvenienced, may be allowed to visit patients on outbreak restricted areas provided that they observe IPC measures.
All visitors must be made aware of the need to decontaminate hands before and after visiting.
Non-essential visitors. Visits from newspaper vendors, hairdressers, mobile libraries and similar services must not be allowed to an outbreak restricted area until the outbreak is declared over and terminal cleaning successfully completed. However, provision of reading materials such as newspapers can be an important part of recovery and can be provided to patients in other ways which do not jeopardise outbreak control. Used reading materials must be disposed of as clinical waste.
Appropriate instructions must be given to contractors before they enter a closed area. However, only work that cannot be postponed until after re-opening of the closed area must be allowed.
9. MANAGEMENT OF SUSPECTED AND CONFIRMED CASES
If a clinical area or unit has both closed and non-closed areas within it, the non-closed areas will remain open to admissions but a risk assessment must be made as to whether patient transfers from the non-closed areas to other clinical areas must be delayed until the risk of the outbreak emerging within the non-closed area is sufficiently low. This risk assessment will take account of the behaviour of the outbreak, the provision of estate and resources to maximise containment of the outbreak, the prevalence within the local community and other local factors. If there is a significant risk that patients in the non-closed areas might be incubating norovirus infection, then it would be prudent to restrict their transfers to other clinical areas for 48hours after their most recent possible contact with a symptomatic case.
if it is urgent or non-urgent. Those patients who require urgent investigations must be allowed to attend the department, e.g. X-ray etc. Contact the Infection Prevention and Control Team for advice. The investigating department must be informed prior to the patient visiting the department. The patient must be fast tracked through, preferably at the end of the session (if possible). Departmental staff must wear gloves and aprons. Strict hand hygiene to be adhered to at all times.
9.1 The definition of closure This definition applies to single-occupancy rooms, bays, wards and other unit areas capable of segregation.
Closure refers to the restriction of incoming and outgoing personnel, equipment, materials (including patient notes) to an unavoidable minimum. The fewer times that the portal of a closed area is crossed, the less is the risk of transmission of virus and further spread to other areas.
Patients must only be transferred for investigations and interventions that cannot be safely delayed.
There must be an obvious boundary between open and closed areas to signal to everyone that restricted access is in place. This boundary must consist of doors and high visibility signage. There must be provision of hand hygiene facilities at each boundary.
All non-essential personnel must be prohibited from entering the closed area. This includes nonessential social visitors of patients.
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Admissions to a closed area must be restricted to patients who are known to have been exposed to norovirus, whether potentially incubating, symptomatic, recovered or deemed unlikely to develop disease (e.g. patient with definite exposure who fails to develop symptoms)
Closed areas must, ideally, be self-contained with hand washing facilities and en suite toilet facilities. The use of commodes and communal toilets may increase the risk of spread in an outbreak and this must be mitigated by the implementation of an intensive and frequent cleaning schedule.
Dedicated Healthcare staff must be assigned to closed areas for each work shift.
9.2 Avoidance of 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 considerations which must form part of a local, multi-agency plan, involving local health protection organisations, Primary Care, Ambulance Service, Nursing and Residential Homes and Local Authorities, to ensure the avoidance of unnecessary admissions to hospital are set out below. The avoidance of admission measures must include:
A sensitive surveillance system to alert all agencies to any increase in norovirus activity and daily situation reports at times of significantly increased activity.
Robust local communication channels between agencies
Timely advice to General Practitioners about the diagnosis and management in the community of norovirus patients including the provision of outreach services for rehydration therapy
The implementation of a hospital norovirus admissions protocol to include: a. Immediate triaging of patients with vomiting and/or diarrhoea to a segregated area
close to the relevant hospital portal (e.g. A&E, Admissions Unit) b. Rapid clinical assessment of the patient by a doctor with full competence to decide on
the destination of the patient.
those cases for which simple discharge home is not sufficiently safe. d. The admission of patients to be restricted only to situations in which the diagnosis is
significantly uncertain or complications are a risk and in which simple rehydration is unlikely to suffice.
9.3 Clinical treatment of Norovirus The mainstay of the clinical treatment of norovirus is the avoidance or correction of dehydration. This may be achieved through any standard oral rehydration regimen in patients who can tolerate oral fluids. For those who cannot, subcutaneous or intravenous administration of appropriate fluids is indicated. These measures are particularly important in the elderly and in those who have underlying conditions or illnesses which render them more vulnerable to the effects of dehydration. Rehydration therapy must be carried out in the community if appropriate. Specialist outreach teams must be established to administer this treatment and thereby avoid admission of the patient to hospital solely for this purpose. Stool samples must be sent from all symptomatic patients and staff as soon as possible. Ensure stool charts are completed for all symptomatic patients.
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9.3.1 Antiemetic drugs These are not recommended routinely although some doctors find them useful. There is no evidence for the efficacy of these drugs in adults and conflicting evidence for their use in children for whom side-effects may be an issue. There is also the risk of compromising IPC measures through masking the infectivity of patients. For example, their use in children may lead to a premature return to school.
9.3.2 Anti diarrhoea drugs These are not recommended routinely but some doctors find them useful in cases where other causes of diarrhoea have been excluded. They can be dangerous in some conditions such as Clostridium difficile disease and may also mask the infectivity of patients.
9.4 Patient discharge Patients must be discharged from hospital as soon as their health permits. Recommendations on discharge are as follows;
Discharge to own home. This can take place at any time irrespective of the stage of the norovirus illness. It is not necessary to delay the discharge of symptomatic
patients or those who may be incubating norovirus
Discharge to nursing or residential homes. Discharge to a home known not to be affected by an outbreak of vomiting and/or diarrhoea must not occur until the patient has been asymptomatic for at least 48hours. However, discharge to a home known to be affected by an outbreak at the time of discharge must not be delayed providing the hoare asymptomatic may be discharged only on the advice of the health protection team and IPCT.
Discharge or transfer to other hospitals or community-based institutions (e.g. prisons). This must be delayed until the patient has been asymptomatic for at least 48hours.
Urgent transfers to other hospitals or within hospitals need an individual risk assessment
10. DEFINING THE END OF AN OUTBREAK
The definition for the end of an outbreak is 48hours after the resolution of vomiting and/or diarrhoea in the last known case and at least 72hours after the initial onset of the last new case. This is also the point at which terminal cleaning has been completed. Often, there is a small number of patients with persistent symptoms and it is advisable to segregate those patients in order to facilitate a return to normal activity. Symptomatic patients may be moved into single rooms or otherwise within a cohort away from the area to be cleaned. There is thought to be little risk of prolonged airborne persistence of virus and terminal cleaning of an area such as a ward can commence immediately after removal of symptomatic patients.
11. EVALUATION AND MONITORING
Implementation of policies and procedures can only be effective if adequate evaluation and monitoring is used to check the system and ensure any shortcomings are identified and dealt with. Managers are responsible for initiating an ongoing monitoring process within their areas of responsibility. From an organisation perspective, the Infection Prevention and Control Committee shall be responsible for monitoring that this Policy and that appropriate actions are being taken to maintain patient safety.
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12. REFERENCES
Welsh Government Draft Communicable Disease Outbreak Plan for Wales (July 2010) Health Protection Agency Guidelines for the management of norovirus outbreaks in acute and community health and social care settings March 2012 Public Health Wales Guidelines on Decontamination of the Environment in Care (Nursing & Residential) Homes during Outbreaks of Viral Gastroenteritis March 2011
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13. APPENDIX 1 DIARRHOEA AND VOMITING OUTBREAK ADVICE
FLOWCHART
Diarrhoea and Vomiting Outbreak Advice Flowchart
-
Pre Outbreak Monitoring
If more than one patient suddenly develops diarrhoea and/or vomiting in a ward area, please do not move the patient until the situation has been discussed with a member of the Infection Prevention & Control Team.
Role of Acute Response Team (ART)
In an outbreak situation, to avoid admitting patients to hospital with symptoms of diarrhoea and vomiting, ART must be contacted to request that they assess the patient in their own home to facilitate admission avoidance where possible.
Surge Capacity Consideration Senior Nurse to discuss with Infection Prevention & Control and Site Manager the potential for Surge Capacity management to accommodate emergency admission activity and continuation of service provision.
Staff Only essential staff to visit ward. Staff must not move between wards. Avoid staff cross cover between affected and non-affected patients. Staff with symptoms to remain off duty until 48 hours symptom free. A specimen must be submitted. Staff with D&V must be referred to Occupational Health. Staff breaks must be taken on the ward.
Steps to Minimise Spread of Diarrhoea & Vomiting
Initial Management
In the event of a bed crisis, any decision to admit to an affected ward must be discussed between the Infection Prevention & Control Team, the Site Manager and the Nurse in Charge of the ward.
Initial Management Contact Ward Manager on entry to ward.
All personnel must perform hand hygiene when entering or leaving the ward, gloves and aprons must be worn. Strict hand washing must be adhered to.
Erect signs advising of ward closure and precautions that need to be implemented; keep entrance door to ward closed.
Where possible, cohort nurse affected patients together.
Patients
Admission to a closed ward must be avoided wherever possible. If this is not feasible, please ensure that all must be consulted before admission to a closed ward.
If a patient is admitted with suspected infectious diarrhoea and vomiting, they must be admitted directly to a ward side room/cubicle.
Observe patients for symptoms of diarrhoea and/or vomiting. Stool samples must be sent from all symptomatic patients. Ensure stool charts are completed for all symptomatic patients.
If a patient requires investigation, e.g. X-Ray, please discuss with Clinician as to urgency and inform the department if patient is being transferred (normally will be placed last on the list). Gloves and aprons must be worn.
Visitor Visiting must be discouraged in all cases when this cannot be avoided visitors must be made aware of the need to decontaminate hands before and after visiting. The frail and elderly may want to refrain from visiting until the outbreak is over. It is advised that children must not visit the ward during an outbreak. Visitors and relatives must be advised not to visit the ward if they have symptoms of diarrhoea
Outbreak Surveillance Infection Prevention & Control Team to conduct daily visits to affected area to monitor progress of outbreak, advise on management arrangements and provide written daily updates.
Environmental
table. Retain food trolley outside immediate ward environment. Daily cleaning & disinfection of all areas to be undertaken using Chlorine Dioxide/Hypochlorite Solution . Additional ad hoc cleaning/disinfection of sanitary to be advised by Infection Prevention & Control Team. All curtains to be changed in affected area.
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14. APPENDIX 2 NOROVIRUS DECISION TREE
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 2
3 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
15
. A
PP
EN
DIX
3
IN
FO
RM
AT
ION
FO
R H
EA
LT
H C
AR
E
WO
RK
ER
LE
AF
LE
T
WH
AT
IS
VIR
AL
GA
ST
RO
EN
TE
RIT
IS?
V
iral g
astr
oe
nte
ritis is u
sua
lly a
self-lim
ite
d, m
ild to
mod
era
te d
isea
se
th
at ofte
n
occu
rs in
ou
tbre
aks in
th
e c
om
mu
nity a
nd
occasio
nally
in
th
e h
osp
ital se
ttin
g.
Clin
ical sym
pto
ms o
f n
ause
a, vo
mitin
g, d
iarr
hoe
a, ab
dom
inal p
ain
, m
ya
lgia
, h
ea
da
che
, m
ala
ise
an
d low
gra
de
fe
ve
r m
ay b
e e
xpe
rie
nce
d b
y ind
ivid
ua
ls.
Ga
str
oin
testin
al sym
pto
ms c
ha
racte
ristica
lly la
st fo
r 2
4 -
48
ho
urs
. A
com
mon
ca
use
of
vir
al ga
str
oen
teritis is d
ue
to
Sm
all
Ro
un
d S
tru
ctu
red
Vir
us (
SR
SV
) /
No
rwalk
-lik
e v
iru
s. T
he
vir
us m
ay b
e id
en
tified
in
the
sto
ols
of
ill in
div
idua
ls.
HO
W IS
IT
TR
AN
SM
ITT
ED
?
Tra
nsm
issio
n c
an
occu
r th
rou
gh
vom
it (
by a
ero
sol / a
irb
orn
e),
by f
ae
cal-
ora
l sp
rea
d o
r b
y c
on
sum
ptio
n o
f co
nta
min
ate
d fo
od
or
wa
ter.
D
urin
g o
utb
reaks o
f vir
al g
astr
oen
teritis w
ith
pa
tie
nts
, sta
ff a
re s
usce
ptible
to
th
e infe
ctio
n d
ue
to
th
eir
clo
se
in
tera
ction
with
pa
tie
nts
. IF
I A
CQ
UIR
E T
HIS
VIR
US
WH
AT
AR
E T
HE
RIS
KS
OF
MY
FA
MIL
Y
AC
QU
IRIN
G IT
?
Th
e v
iru
s is s
pre
ad
ea
sily
fro
m p
ers
on
to
pe
rso
n s
o y
ou
r fa
mily
are
po
ssib
ly a
t ri
sk o
f a
cqu
irin
g th
e v
iru
s if
yo
u a
re in
clo
se
co
nta
ct w
ith
th
em
wh
en
yo
u h
ave
clin
ica
l sym
pto
ms. T
he
incu
ba
tio
n p
eriod
is 1
0-5
0 h
ou
rs.
HO
W C
AN
I R
ED
UC
E T
HE
RIS
KS
TO
MY
SE
LF
OF
AC
QU
IRIN
G T
HIS
VIR
US
?
F
ollo
w th
e a
dd
itio
na
l in
fectio
n c
on
tro
l a
dvic
e d
urin
g th
e o
utb
reak.
E
nsu
re y
ou
de
con
tam
ina
te y
ou
r h
an
ds w
ith
alc
oh
ol h
an
d r
ub
.
W
ash
an
d d
ry y
ou
r h
an
ds b
efo
re a
nd
aft
er
pa
tie
nt / e
nvir
onm
en
tal co
nta
cts
.
W
ear
glo
ve
s a
nd
ap
ron
s fo
r co
nta
ct w
ith
infe
cte
d p
atie
nts
/ e
nvir
onm
en
t.
D
o n
ot ea
t a
ny f
oo
d p
rod
ucts
in
th
e infe
cte
d w
ard
envir
on
me
nt.
If
yo
ur
un
ifo
rm b
ecom
es c
on
tam
ina
ted
with
vom
it o
r fa
ece
s, it m
ust b
e
ch
ang
ed
im
me
dia
tely
.
WH
AT
DO
I D
O IF
I B
EC
OM
E U
NW
ELL
WIT
H V
IRA
L G
AS
TR
OE
NT
ER
ITIS
?
R
epo
rt a
ny s
ym
pto
ms to
yo
ur
ma
nag
er
and
ma
inta
in c
on
tact w
ith
yo
ur
man
age
r.
D
O N
OT
com
e to
wo
rk, eve
n if
yo
u f
eel re
lative
ly w
ell.
P
lea
se
pro
vid
e a
sto
ol spe
cim
en
if
yo
u h
ave
dia
rrho
ea
and
eithe
r ta
ke
it to
yo
ur
GP
or
ne
are
st M
icro
bio
log
y L
abo
rato
ry.
D
o n
ot re
turn
to
wo
rk u
ntil yo
u a
re s
ym
pto
m f
ree
fo
r 4
8 h
ou
rs.
C
on
tact th
e O
ccu
pa
tio
na
l H
ealth
De
pa
rtm
en
t o
n e
xte
nsio
n 3
21
7.
WH
AT
DO
I D
O IF
I F
EE
L U
NW
ELL
IN
WO
RK
WIT
H N
AU
SE
A / V
OM
ITIN
G /
DIA
RR
HO
EA
?
R
epo
rt to
yo
ur
ma
nag
er
imm
ed
iate
ly w
ho
will
arr
ang
e f
or
yo
u to
be
re
lieve
d o
f yo
ur
du
tie
s A
SA
P.
If
yo
u v
om
it in
a s
taff
to
ilet o
r o
the
r a
rea
ple
ase
rep
ort
th
is to
yo
ur
ma
na
ge
r.
NB
. S
taff
to
ilets
clo
sed
off f
or
24
hou
rs to
pre
ve
nt a
ero
sol sp
read
to
oth
er
sta
ff.
WIL
L A
CT
IVE
IN
FE
CT
ION
WIT
H V
IRA
L G
AS
TR
OE
NT
ER
ITIS
ME
AN
I W
ILL B
E
IMM
UN
E F
RO
M T
HE
IN
FE
CT
ION
IN
TH
E F
UT
UR
E?
S
ho
rt te
rm im
mun
ity h
as b
ee
n k
no
wn
to
la
st fo
r a
pp
roxim
ate
ly 1
4 w
eeks b
ut lo
ng
te
rm im
mu
nity is v
aria
ble
. It is
po
ssib
le fo
r yo
u to
ha
ve
vir
al g
astr
oe
nte
ritis a
gain
in
th
e fu
ture
.
WH
AT
IS
TH
E C
RIT
ER
IA F
OR
SU
SP
EC
TIN
G A
N O
UT
BR
EA
K O
N M
Y W
AR
D?
R
apid
/ s
udd
en
on
se
t of
dia
rrh
oe
a a
nd
/ o
r vo
mitin
g in
pa
tien
ts a
nd
sta
ff w
ith
n
o e
xpla
inab
le c
au
se
e.g
. ch
ang
e o
f m
edic
atio
n.
Illn
ess d
ura
tio
n 1
2-6
0 h
ours
.
V
om
itin
g in
ove
r 5
0%
of
sym
pto
ma
tic p
atie
nts
. W
HA
T A
RE
MY
IN
DIV
IDU
AL
RE
SP
ON
SIB
ILIT
IES
DU
RIN
G A
N O
UT
BR
EA
K O
F
DIA
RR
HO
EA
AN
D V
OM
ITIN
G O
N M
Y W
AR
D?
M
ain
tain
hig
h s
tand
ard
s o
f e
nviro
nm
enta
l cle
an
ing / h
yg
iene
.
M
ain
tain
hig
h s
tand
ard
s o
f h
an
d d
eco
nta
min
atio
n a
nd
hyg
iene.
Em
pha
sis
e th
e im
port
ance
of
han
dw
ashin
g a
nd u
se
of
alc
oho
l h
an
d r
ub
post
han
dw
ashin
g.
E
nsure
corr
ect
deco
nta
min
atio
n o
f a
ny v
om
it /
dia
rrh
oe
a o
r a
ny o
the
r b
ody
flu
id s
pill
ag
e a
s p
er
He
alth
Bo
rad b
od
y f
luid
sp
illa
ge p
olic
y.
E
nsure
yo
u r
eport
all
new
ca
ses t
o th
e I
nfe
ction C
ontr
ol T
eam
as s
oon a
s
possib
le.
Is
ola
te o
r co
ho
rt n
urs
e s
ym
pto
matic p
atie
nts
and p
ers
ons e
xp
ose
d to
th
e
viru
s,
wh
o m
ay w
ell
be in
cub
atin
g t
he c
ond
itio
n.
O
ffe
r p
atie
nts
han
dw
ash fa
cili
tie
s / w
ipes a
fte
r to
ileting
.
O
bta
in fa
eca
l sp
ecim
ens fro
m a
ll aff
ecte
d p
atie
nts
.
D
o n
ot
allo
w p
atie
nts
to e
at fo
od
/ f
luid
s t
hat
have
be
en left
ope
n o
n t
heir
locke
rs e
.g. fr
uit in b
ow
ls.
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 2
4 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
A
vo
id tra
nsfe
r of
pa
tie
nts
to
un
aff
ecte
d w
ard
s / d
ep
art
me
nts
or
oth
er
ho
spita
ls
(un
less m
edic
ally
urg
en
t a
nd
afte
r co
nsulta
tio
n w
ith
in
fection
co
ntr
ol sta
ff).
T
he
prio
rity
is to
sto
p t
he
sp
read
of
the
vir
us to
oth
er
are
as.
P
atie
nts
, if c
linic
ally
we
ll, m
ay b
e d
ischa
rged
to
th
eir o
wn
ho
me
s (
no
t n
urs
ing
/ re
sid
en
tial h
om
es).
M
inim
ise
yo
ur
mo
vem
en
ts th
rou
gh
ou
t th
e h
ospita
l to
pre
ve
nt sp
rea
d o
f th
e
vir
us. G
o s
tra
igh
t h
om
e a
fte
r w
ork
.
B
ank a
nd
ag
en
cy n
urs
e's
mo
vem
en
ts m
ust b
e lim
ited
.
A
ny e
sse
ntial d
iag
nostic p
roce
du
re in
oth
er
de
pa
rtm
en
ts -
lia
ise
with
the
IP
CT
.
re
lative
ad
vis
ed
to
pla
ce
in
dom
estic w
ashin
g m
achin
e.
D
ocum
en
t all
ep
iso
des o
f sym
pto
ms w
ith
pa
tien
ts e
.g. sto
ol ch
art
.
E
nsu
re a
ll vis
ito
rs a
re info
rmed
th
at th
ere
is a
n o
utb
reak o
n th
e w
ard
an
d
ca
ution
th
em
th
at th
ey m
ay b
e e
xp
ose
d to
th
e in
fectio
n.
E
nsu
re p
atie
nts
and
re
lative
s h
ave
acce
ss to
info
rma
tio
n le
afle
ts r
eg
ard
ing
th
e infe
ctio
n (
i.e
. in
form
atio
n lea
fle
t a
nd
vis
ito
r in
form
atio
n le
afle
t).
W
here
ve
r p
ossib
le, e
xclu
de
ch
ildre
n a
nd
th
e f
rail
/ e
lde
rly f
rom
th
e a
ffe
cte
d
are
a.
A
dvis
e r
ela
tive
s n
ot to
vis
it if
the
y a
re fe
elin
g u
nw
ell
or
ha
ve
ha
d d
iarr
ho
ea
a
nd
/ o
r vo
mitin
g(e
xclu
de
fro
m v
isitin
g u
ntil 72
hrs
asym
pto
ma
tic).
A
dvis
e r
ela
tive
s to
use
alc
oh
ol h
and
ru
b o
n e
nte
ring
an
d le
avin
g w
ard
. W
HE
N IS
IT
SA
FE
TO
RE
-OP
EN
A B
AY
OR
WA
RD
PO
ST
IN
FE
CT
ION
?
T
his
will
be
de
cid
ed
by th
e In
fectio
n P
reve
ntion
an
d C
on
trol T
eam
in
lia
ison
w
ith
Ho
tel S
erv
ice
s a
nd
lin
e m
an
ag
ers
. D
o n
ot ta
ke
th
is d
ecis
ion
on
by
yo
urs
elf.
T
he
min
imum
re
qu
irem
en
t is
fo
r all
pa
tie
nts
to
be
sym
pto
m fre
e fo
r 4
8 h
ou
rs.
T
he
wa
rd e
nvir
onm
en
t a
nd
eq
uip
men
t m
ust b
e th
oro
ug
hly
cle
an
ed
an
d
dis
infe
cte
d p
rio
r to
re
op
enin
g (
cu
rtain
s c
ha
ng
ed
).
A
ny d
ispo
sab
le ite
ms e
.g. su
ction
ca
the
ters
in
aff
ecte
d b
ays m
ust b
e
dis
po
sed
of
an
d r
epla
ce
d.
T
he
Infe
ctio
n P
reve
ntio
n a
nd
Con
tro
l T
eam
will
co
nfirm
wh
en
th
e w
ard
is
rea
dy to
acce
pt n
ew
pa
tien
ts.
Fo
r a
ny f
urt
he
r in
form
ation
, p
lease
co
nta
ct th
e In
fectio
n P
reve
ntio
n &
Con
tro
l D
epa
rtm
en
t
DE
PA
RT
ME
NT
OF
IN
FE
CT
ION
PR
EV
EN
TIO
N &
CO
NT
RO
L
VIR
AL
GA
ST
RO
EN
TE
RIT
IS
INF
OR
MA
TIO
N F
OR
H
EA
LT
H C
AR
E W
OR
KE
RS
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 2
5 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
16
. A
PP
EN
DIX
4
IN
FO
RM
AT
ION
FO
R P
AT
IEN
TS
LE
AF
LE
T
WH
AT
IS
VIR
AL
GA
ST
RO
EN
TE
RIT
IS?
A
viru
s k
no
wn
as s
ma
ll ro
un
d s
tructu
red
viru
s (
SR
SV
) is
a f
requ
en
t ca
use
of
dia
rrh
oea
an
d v
om
itin
g in
th
e c
om
mu
nity a
nd
is m
ost
com
mo
n
W
HY
IS
IT
A P
RO
BLE
M?
The
se
sm
all
rou
nd s
tructu
red
viru
se
s (
SR
SV
) ca
use
sym
pto
ms o
f -3
da
ys a
nd
the
pe
rson
will
ha
ve
d
iarr
ho
ea a
nd
/ o
r vo
mitin
g.
Som
e p
eop
le m
ay h
ave
a r
ais
ed
te
mp
era
ture
, h
ead
ache
s a
nd
ach
ing lim
bs. T
he
illn
ess is u
su
ally
mild
in
na
ture
an
d g
ets
bette
r qu
ickly
. S
RS
V d
oe
s h
ow
eve
r spre
ad
ea
sily
in
th
e h
osp
ita
l d
ue
to
the
clo
se
con
tact b
etw
ee
n p
atien
ts a
nd
sta
ff.
La
rge
n
um
be
rs o
f pa
tie
nts
and
sta
ff c
an
be
in
vo
lve
d a
nd
it is
im
po
rtant
to s
top
th
e illn
ess f
rom
sp
rea
din
g a
rou
nd t
he
ho
sp
ita
l o
r to
rela
tive
s a
nd
fr
iend
s.
HO
W D
OE
S T
HIS
AF
FE
CT
ME
?
If y
ou
be
co
me
un
we
ll o
n t
he
wa
rd y
ou
ma
y b
e m
ove
d to
a s
ide
roo
m o
r to
an
are
a w
ith
oth
er
pa
tie
nts
with
th
e s
am
e illn
ess.
Yo
u m
ust
ha
ve
as
few
vis
ito
rs a
s p
ossib
le a
nd t
he
y w
ill n
ee
d t
o w
ash
th
eir h
an
ds b
efo
re
an
d a
fte
r see
ing y
ou
. W
ILL
I N
EE
D T
RE
AT
ME
NT
?
An
tib
iotics a
re n
ot eff
ective
aga
inst
this
vira
l in
fection
. T
he
ma
in
trea
tme
nt
is m
akin
g s
ure
yo
u d
rin
k p
len
ty o
f flu
id.
If
yo
u d
eve
lop
d
iarr
ho
ea a
nd
vo
mitin
g a
sto
ol sam
ple
may b
e s
ent
to t
he
la
bo
rato
ry f
or
testin
g.
On
ce
th
e illn
ess is o
ve
r no
fu
rth
er
actio
n is n
ece
ssa
ry a
nd
yo
ur
trea
tme
nt
will
co
ntin
ue
as b
efo
re.
CA
N I H
AV
E V
ISIT
OR
S?
Ye
s y
ou
ca
n h
ave
vis
ito
rs b
ut
we
ad
vis
e t
ha
t yo
u a
nd
yo
ur
fam
ily
restr
ict
the
am
oun
t of
vis
itin
g.
Alth
ou
gh
th
e s
ym
pto
ms a
re m
ild,
ch
ildre
n m
ust b
e d
iscou
rage
d f
rom
com
ing t
o v
isit y
ou
, a
s th
ey
ma
y b
e p
art
icula
rly s
usce
ptib
le t
o th
e v
iru
s.
Frie
nd
s o
r re
lative
s t
ha
t a
re u
nw
ell
or
suff
erin
g f
rom
dia
rrh
oea
an
d v
om
itin
g t
hem
se
lve
s m
ust
als
o n
ot
vis
it.
If
yo
u h
ave
an
y c
on
ce
rns a
t a
ll a
bou
t som
eo
ne
vis
itin
g
ple
ase d
iscuss th
is w
ith
a d
octo
r or
nu
rse.
To p
reve
nt
the
sp
read
of
infe
ction
yo
ur
vis
ito
rs m
ust a
vo
id v
isitin
g o
the
r w
ard
s
an
d h
osp
ita
l fo
od
esta
blis
hm
en
ts w
he
re p
ossib
le.
DO
VIS
ITO
RS
NE
ED
TO
TA
KE
PR
EC
AU
TIO
NS
WH
EN
VIS
ITIN
G M
E?
Vis
ito
rs m
ust
wa
sh
the
ir h
an
ds t
ho
rou
gh
ly b
oth
befo
re a
nd a
fte
r vis
itin
g
yo
u.
It
is a
lso
ad
vis
ab
le t
o k
eep
yo
ur
num
be
r of
vis
ito
rs to
a m
inim
um
a
s t
he
y m
ay p
ick u
p the
viru
s w
he
n o
n t
he
wa
rd.
It
is im
po
rtan
t th
at
yo
ur
rela
tive
s /
vis
ito
rs d
o n
ot
vis
it y
ou
if
the
y fe
el un
we
ll o
r ha
ve
n
au
se
a (
fee
ling q
ue
asy)
or
ha
ve
dia
rrho
ea
an
d v
om
itin
g a
s th
is m
ay
ca
use
fu
rthe
r spre
ad
of
illne
ss in
th
e h
osp
ita
l.
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 2
6 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
D
EP
AR
TM
EN
T O
F I
NF
EC
TIO
N P
RE
VE
NT
ION
& C
ON
TR
OL
V
IRA
L G
AS
TR
OE
NT
ER
ITIS
INF
OR
MA
TIO
N F
OR
PA
TIE
NT
S I
N
HO
SP
ITA
L
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 2
7 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
17
. A
PP
EN
DIX
5
IN
FO
RM
AT
ION
FO
R V
ISIT
OR
S L
EA
FL
ET
WH
AT
IS
TH
E P
RO
BLE
M?
T
he
re is a
n o
utb
rea
k o
f vira
l ga
str
oe
nte
ritis o
n t
his
wa
rd a
nd
te
sts
are
ta
kin
g p
lace
to
fin
d th
e s
pe
cific
cau
se
. W
HA
T S
YM
PT
OM
S D
O T
HE
PA
TIE
NT
S H
AV
E?
A
ffe
cte
d p
atien
ts a
re s
uff
erin
g f
rom
na
usea
/vo
mitin
g a
nd
dia
rrh
oea
.
Th
is i
s n
ot
a s
eri
ou
s ill
ne
ss. S
ym
pto
ms g
en
era
lly la
st
2-3
da
ys.
WH
Y A
RE
PA
TIE
NT
S IS
OL
AT
ED
IN
SID
ER
OO
MS
OR
BA
YS
?
We isola
te p
atien
ts w
ho
are
suff
erin
g f
rom
dia
rrh
oe
a s
o th
at risk o
f sp
rea
d to
oth
er
pa
tie
nts
, sta
ff a
nd
vis
ito
rs is r
ed
uce
d.
HO
W A
RE
PA
TIE
NT
S T
RE
AT
ED
?
In t
he
ma
in b
y r
ep
lacin
g f
luid
s in
to th
e p
atie
nt w
hic
h h
ave
be
en
lo
st
from
th
e b
od
y t
hro
ugh
dia
rrh
oe
a.
Bu
t e
ach p
atie
nt w
ill b
e t
rea
ted
as
ind
icate
d b
y s
ym
pto
ms.
WH
AT
IS
TH
E R
ISK
TO
ME
AN
D M
Y F
AM
ILY
?
The
viru
s is s
pre
ad
ve
ry e
asily
fro
m p
ers
on
to p
ers
on a
nd
fro
m
co
nta
min
ate
d h
ard
su
rfa
ce
s a
nd
be
d lin
en,
so v
isito
rs to
a p
atie
nt
suff
erin
g d
iarr
hoe
a s
ym
pto
ms c
ou
ld p
ossib
ly b
e a
ffe
cte
d.
WH
AT
PR
EC
AU
TIO
NS
MU
ST
I T
AK
E?
If
yo
u a
re o
nly
pa
yin
g a
so
cia
l vis
it t
o th
e p
atie
nt,
we
wo
uld
ask y
ou
no
t
Restr
ict
the
num
be
r of
vis
ito
rs.
Do n
ot b
rin
g c
hild
ren
to
vis
it.
Do n
ot vis
it o
the
r pa
tien
ts d
urin
g t
his
tim
e.
Extr
a p
reca
ution
s m
ay b
e n
ece
ssa
ry s
uch
as w
ea
rin
g a
pla
stic a
pro
n
an
d g
love
s if
yo
u a
re g
ivin
g h
an
ds o
n c
are
to
yo
ur
rela
tive
or
frie
nd
, in
a
dd
itio
n t
o g
oo
d h
an
d w
ash
ing.
Ple
ase
ask a
mem
be
r of
sta
ff fo
r he
lp o
r if o
the
r in
form
ation
is r
equ
ire
d.
Ple
as
e d
o n
ot
vis
it i
f yo
u f
ee
l u
nw
ell o
r h
ave
na
us
ea
(fe
elin
g q
ue
as
y)
or
ha
ve
dia
rrh
oe
a a
nd
vo
mit
ing
.
Wa
sh
and
dry
yo
ur
ha
nd
s
an
d a
pp
ly a
lco
ho
l h
and
rub b
efo
re
le
avin
g th
e w
ard
.
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 2
8 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
Pro
du
ce
d b
y t
he
Infe
ctio
n P
reve
ntion
& C
on
tro
l T
ea
m,
Nove
mb
er
20
01
Upd
ate
d A
ug
ust 20
02
, U
pd
ate
d F
eb
rua
ry 2
003
; U
pd
ate
d 2
009
D
EP
AR
TM
EN
T O
F IN
FE
CT
ION
PR
EV
EN
TIO
N &
CO
NT
RO
L
VIR
AL
GA
ST
RO
EN
TE
RIT
IS
IN
FO
RM
AT
ION
FO
R V
ISIT
OR
S
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 2
9 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
18
. A
PP
EN
DIX
6
IN
FO
RM
AT
ION
FO
R R
EL
AT
IVE
S/V
ISIT
OR
S
WH
EN
A P
AT
IEN
T IS
IN
IS
OL
AT
ION
LE
AF
LE
T
RE
ME
MB
ER
H
an
dw
ash
ing /
use o
f a
lcoh
ol h
and
rub a
re o
ne
of
the
mo
st
impo
rtan
t w
ays o
f p
reve
ntin
g t
he s
pre
ad o
f in
fectio
n.
If y
ou
ha
ve
an
y f
urt
he
r qu
estio
ns th
en p
lea
se
sp
ea
k w
ith
the
wa
rd s
taff
o
r ask t
o s
pea
k to
the
Infe
ction
Pre
ve
ntion
and
Co
ntr
ol N
urs
e.
Dep
art
me
nt
of
Infe
cti
on
Pre
ven
tio
n a
nd
Co
ntr
ol
INF
OR
MA
TIO
N F
OR
R
ELA
TIV
ES
/ V
ISIT
OR
S W
HE
N
A P
AT
IEN
T IS
IS
OLA
TE
D IN
H
OS
PIT
AL
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 3
0 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
1
Fo
r w
ha
t re
as
on
are
pa
tie
nts
nu
rse
d i
n is
ola
tio
n in
h
os
pit
al?
(a)
The
pa
tien
t m
ay b
e m
ore
at
risk o
f a
cqu
irin
g a
n i
nfe
ctio
n
if t
he
ir im
mun
e s
yste
m o
r re
sis
tan
ce
is im
pa
ire
d.
A r
oom
of
the
ir o
wn
w
ill re
du
ce
th
e risks of
acqu
irin
g in
fection
from
oth
er
pa
tie
nts
on
th
e w
ard
.
or
(b
) T
he
pa
tien
t m
ay h
ave
an
infe
ction
; -
a r
oo
m o
f th
eir o
wn
a
nd
add
itio
na
l n
urs
ing p
roce
du
res w
ill p
reve
nt
sp
rea
d o
f th
e infe
ction
to
oth
er
vu
lne
rab
le p
atie
nts
on th
e w
ard
. 2
As
a v
isit
or
to a
pa
tie
nt
iso
late
d d
ue
to
an
in
fecti
on
, a
re t
he
re a
ny r
isks
to
my h
ea
lth
by v
isit
ing
th
em
?
The
ma
jority
of
infe
ctio
ns w
ill p
ose
no
ris
k a
t a
ll to
th
e h
ea
lth
of
vis
ito
rs.
It
is a
dvis
ab
le t
o lia
ise
with
wa
rd s
taff
prio
r to
brin
gin
g in
ba
bie
s
an
d
sm
all
ch
ildre
n,
as
the
y
ma
y
be
vu
lne
rab
le
to
infe
ction
. T
he
re w
ill b
e a
nee
d,
wh
en
th
e p
atien
t ha
s c
ert
ain
in
fectiou
s d
isea
se
s,
for
the
wa
rd s
taff
to
en
qu
ire
wh
eth
er
vis
ito
rs
ha
ve
p
revio
usly
h
ad
th
e
dis
ea
se
o
r b
ee
n
imm
un
ised
e
.g.
mum
ps,
mea
sle
s,
rub
ella
, ch
icken
po
x
/ sh
ingle
s
an
d
tub
erc
ulo
sis
of
lun
g.
The
wa
rd s
taff
will
se
ek a
dvic
e f
rom
the
In
fectio
n P
reve
ntio
n a
nd
Co
ntr
ol T
eam
if
the
re a
re a
ny q
ue
ries.
3
As
a v
isit
or,
wh
at
do
I n
ee
d t
o d
o w
he
n v
isit
ing
a
pa
tie
nt
in is
ola
tio
n?
(a)
Prio
r to
ente
rin
g t
he
iso
lation
room
, spe
ak w
ith
th
e w
ard
sta
ff i
n o
rde
r to
asce
rta
in w
ha
t is
re
qu
ire
d o
f yo
u w
he
n
vis
itin
g.
(b
) d
iarr
ho
ea
an
d v
om
itin
g,
the
n y
ou
must
no
t vis
it u
ntil yo
u a
re w
ell.
(c)
En
su
re a
ny c
uts
/ w
oun
ds y
ou
ma
y h
ave
are
co
ve
red
with
a
wa
terp
roof
pla
ste
r /
dre
ssin
g.
(d
) D
urin
g y
ou
r vis
it t
o t
he isola
tio
n r
oom
, yo
u w
ill n
ot
ne
ed
to
pu
t o
n g
love
s a
nd a
pro
ns.
If
yo
u a
re a
ssis
tin
g t
he
nu
rses
to c
arr
y o
ur
ca
re p
roce
du
res t
he
n y
ou
will
be
requ
ire
d t
o
we
ar
glo
ve
s a
nd
ap
ron.
N
B
Nurs
es
we
ar
glo
ve
s
an
d
ap
ron
s
with
in
iso
lation
roo
ms a
s t
he
y h
ave
co
nta
ct
with
lots
of
oth
er
vu
lne
rab
le
pa
tien
ts a
nd
ne
ed
to
pre
ve
nt
cro
ss infe
ctio
n.
(e
) B
efo
re
lea
vin
g
the
is
ola
tio
n
roo
m,
wash
a
nd
d
ry
han
ds
th
oro
ug
hly
a
nd
a
pp
ly a
lco
ho
l h
an
d ru
b fr
om
th
e t
roll
ey o
uts
ide t
he
ro
om
. (f
) If
yo
u a
re w
ash
ing u
sed
nig
htw
ea
r / to
we
ls the
n e
nsu
re y
ou
ta
ke
them
ho
me
in
a p
lastic c
arr
ier
ba
g.
Ite
ms c
an b
e m
ach
ine
wa
sh
ed
on
th
e h
otte
st p
ossib
le w
ash
fo
r th
e fa
bric a
nd t
hen
drie
d a
nd
iro
ne
d in
the
n
orm
al w
ay.
Alte
rna
tive
ly,
ite
ms c
an
be
ha
nd w
ash
ed
in
th
e h
otte
st
po
ssib
le w
ate
r fo
r th
e fa
bric.
It is
pre
fera
ble
tha
t ite
ms a
re w
ash
ed
on
th
eir o
wn
and
no
t m
ixe
d w
ith
oth
er
ho
use
ho
ld w
ash
ing.
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 3
1 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
19
. A
PP
EN
DIX
7
HA
ND
HY
GIE
NE
IN
FO
RM
AT
ION
LE
AF
LE
T
FA
CT
S A
BO
UT
HA
ND
WA
SH
ING
1.
Ha
nd
wa
sh
ing
ca
n s
ign
ific
antly r
edu
ce
th
e le
ve
l of
pote
ntia
lly h
arm
ful
germ
s a
nd
bacte
ria
on
yo
ur
skin
. 2.
Ha
nd
wa
sh
ing
is a
sim
ple
and
im
port
ant m
eth
od
for
red
ucin
g infe
ctio
ns
bein
g p
asse
d fro
m p
ers
on
to p
ers
on.
3.
Ha
nd
wa
sh
ing
with
liq
uid
so
ap
an
d w
arm
wa
ter
is a
ll th
at
is n
ee
de
d to
eff
ective
ly k
ill m
ost g
erm
s a
nd
ba
cte
ria.
4.
Eve
n if
docto
rs a
nd n
urs
es a
re w
earin
g p
rote
ctive
glo
ve
s,
han
dw
ashin
g is
still
req
uire
d to
ensu
re h
and
s a
re c
lean
aft
er
rem
ova
l o
f g
love
s.
WH
AT
MU
ST
I U
SE
TO
CLE
AN
MY
HA
ND
S?
Tra
ditio
na
l w
ashin
g w
ith
liq
uid
so
ap
an
d w
ate
r is
th
e e
asie
st o
ptio
n.
th
ey w
ill b
e h
ap
py t
o r
epla
ce it fo
r yo
u.
S
taff
use a
lco
ho
l h
an
d g
el
all
yo
u d
o is r
ub th
e g
el o
nto
vis
ibly
cle
an
h
an
ds a
fte
r e
ach p
atie
nt co
nta
ct a
nd le
t it d
ry (
NB
. If h
an
ds a
re v
isib
ly
dirty
th
en
ha
nd
wa
shin
g a
t a s
ink is r
eq
uire
d).
HO
W O
FT
EN
MU
ST
YO
U C
LE
AN
YO
UR
HA
ND
S?
W
e a
sk t
hat a
ll p
atie
nts
, vis
ito
rs a
nd
sta
ff fo
llow
th
is s
imp
le a
dvic
e:
- P
AT
IEN
TS
P
LE
AS
E C
LE
AN
YO
UR
HA
ND
S:
-
Be
fore
me
als
.
A
fte
r e
ach t
ime y
ou u
se th
e t
oile
t, b
ath
room
or
a c
om
mo
de.
If y
ou h
ave
ha
d s
kin
to
skin
co
nta
ct
with
an
oth
er
patie
nt.
V
ISIT
OR
S
PL
EA
SE
CL
EA
N Y
OU
R H
AN
DS
: -
A
fte
r vis
itin
g th
e to
ilet
or
bath
room
.
B
efo
re h
elp
ing
a p
atie
nt w
ith
th
eir m
eal.
in
fectio
n.
ST
AF
F
MU
ST
CL
EA
N T
HE
IR H
AN
DS
: -
E
ach t
ime t
hey h
ave
direct
co
nta
ct
with
a p
atie
nt (t
ouch
ing).
B
etw
een
co
nta
ct w
ith
diffe
ren
t p
atie
nts
.
B
efo
re h
an
dlin
g fo
od
or
me
dic
ines.
A
fte
r h
elp
ing p
atie
nts
to
use t
he t
oile
t, b
ath
room
or
com
mo
de
s.
B
efo
re a
nd a
fter
glo
ve
s a
re w
orn
.
A
fte
r co
nta
min
ation b
y b
od
ily f
luid
s.
A
fte
r u
sin
g th
e to
ilet.
A
t th
e b
eg
innin
g a
nd
end o
f e
ach
sh
ift o
r b
reak.
WH
AT
DO
I U
SE
TO
DR
Y M
Y H
AN
DS
?
P
lease
use
the
pa
per
tow
els
th
at a
re a
va
ilable
ab
ove
eve
ry s
ink. If th
ey
are
em
pty
, p
lease t
ell
a m
em
ber
of sta
ff w
ho w
ill b
e h
ap
py t
o r
epla
ce
them
.
T
o p
reve
nt
skin
on y
our
han
ds b
ecom
ing d
ry, p
lease
use
th
e m
ois
turisin
g
han
d c
ream
th
at
is a
va
ilable
in t
he g
ree
n d
isp
en
se
rs
HY
WE
L D
DA
LO
CA
L H
EA
LT
H B
OA
RD
Data
base N
o:
322
P
ag
e 3
2 o
f 32
V
ers
ion
1.0
Noro
virus, D
iarr
ho
ea a
nd/o
r V
om
itin
g O
utb
reak P
olic
y
HA
ND
WA
SH
ING
H
OW
TO
DO
IT
RIG
HT
! T
he
ha
nd
wa
sh
ing s
tage
s s
ho
wn
be
low
mu
st
take
15
-30
se
co
nd
s a
nd
is
su
ita
ble
fo
r all
wa
rds a
nd
de
pa
rtm
en
ts.
Wet h
an
ds, a
pp
ly 3
-5m
ls o
f liq
uid
so
ap t
o h
an
ds a
nd r
ub t
og
eth
er
5 tim
es fo
r e
ach
of
the s
ix s
teps s
how
n.
Alte
rna
tive
ly,
1m
l of
alc
oho
l g
el at th
e e
nd
of
yo
ur
bed
ca
n b
e u
se
d to
d
eco
nta
min
ate
vis
ibly
cle
an h
an
ds.
If
yo
u
requ
ire
fu
rthe
r in
form
ation
, p
lease
co
nta
ct
the
Infe
ctio
n
Pre
ve
ntio
n a
nd
Co
ntr
ol D
ep
art
me
nt.
T
hank y
ou f
or
yo
ur
co-o
pe
ratio
n.
DE
PA
RT
ME
NT
OF
IN
FE
CT
ION
PR
EV
EN
TIO
N &
C
ON
TR
OL
PR
OM
OT
ING
H
AN
D H
YG
IEN
E
H
EL
P U
S T
O P
RO
TE
CT
YO
U
AG
AIN
ST
IN
FE
CT
ION
5.3
Pa
lm t
o p
alm
.R
igh
t p
alm
ove
r le
ft d
ors
um
an
d le
ft p
alm
ove
r ri
gh
t d
ors
um
.P
alm
to
pa
lm
fin
ge
rs in
terl
ace
d.
Ba
cks
of
fin
ge
rs t
o o
pp
osi
ng
pa
lms
wit
h f
ing
ers
inte
rlo
cke
d.
Ro
tati
on
al
rub
bin
g o
f ri
gh
t th
um
b
cla
spe
d in
left
pa
lm a
nd
vic
e v
ers
a.
Ro
tati
on
al
rub
bin
g,
ba
ckw
ard
s a
nd
fo
rwa
rds
wit
h c
lasp
ed
fin
ge
rs o
f ri
gh
t h
an
d in
left
pa
lm
an
d v
ice
ve
rsa
.
12
3
45
6
Han
dw
ash
ing
Recommended