MANAGEMENT OF AN OUTBREAK OF DIARRHOEA AND/OR VOMITING IN A CARE HOME SETTING

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1 MANAGEMENT OF AN OUTBREAK OF DIARRHOEA AND/OR VOMITING IN A CARE HOME SETTING

2 PAGE 2 Contents Page Introduction and contact telephone numbers 3 Action sheet for managers 4 Action sheet for nursing and care staff 6 Action sheet for cleaners and care staff 8 Action sheet for catering staff 10 Appendices Appendix 1 Daily log sheet for symptomatic residents 11 Appendix 2 Daily log sheet for symptomatic staff 12 Appendix 3 Notice to visitors 13 Appendix 4 Effective hand washing technique poster 14 Appendix 5 Hand washing reminders poster for visitors 15

3 PAGE 3 INTRODUCTION Every worker within a care home, irrespective of discipline, is in effect an infection control practitioner and thus should have some basic but fundamental understanding of this subject. The format, of this guidance has been deliberately chosen to enable photocopying of each individual workers specific infection control role during an outbreak of diarrhoea and/or vomiting. Within the general community, circulation of viruses that cause gastro-enteritis is common causing sporadic and sometimes small clusters of cases. Large outbreaks occur frequently, particularly during winter months and often in care homes, hospitals and hotels. In England the number of cases of viral gastro-enteritis infection associated with outbreaks has increased during recent years, with the greatest burden of illness on the institutionalised elderly. There is probably little that can be done to prevent the introduction of these viruses into homes the annual winter flurry of outbreaks is a regular feature on the infection control calendar. However, outbreaks involving these viruses among residents and staff are just not restricted to the winter months and have a significant effect on the homes activities. Infection is usually relatively mild, lasting hours. Abdominal cramps and nausea are usually the first symptoms, followed by vomiting and/or diarrhoea. Forceful projectile vomiting is particularly characteristic. Diarrhoea is usually mild, with no blood or mucus in the stool. Other symptoms may include anorexia, lethargy, myalgia, headache and fever. Illness may be debilitating in residents. An outbreak can be defined as two or more linked cases of the same illness or when the number of cases of the same illness unaccountably exceeds the expected number. If you identify or suspect you have a gastro-intestinal outbreak e.g. several cases of vomiting and/or diarrhoea, please contact: Health Protection Unit Environmental Health Officer Primary Care Trust Community Infection Control Nurse Commission for Social Care Inspection Tel: Fax: Tel: Fax: Tel: Fax: Tel: Fax: Early reporting of suspected outbreaks is essential for effective management.

4 PAGE 4 ACTION Complete a list of affected residents and staff (appendix 1 and 2) and update daily, with details of new cases and when existing cases become asymptomatic. If possible isolate all symptomatic residents in their rooms until they are symptom free for 48 hours, i.e. they have no further vomiting and/or diarrhoea. The Community Infection Control Nurse (CICN) or Environmental Health Officer (EHO) will liaise with you about this. Advise all symptomatic staff that they must stay off work until they are symptom free for 48 hours. In line with duty of care it maybe prudent to close the home temporarily to admissions including respite clients. The home will usually be able to open again when no new cases have presented with symptoms for 48 hours. The HPU/CICN or EHO will liaise with you about this. Post a notice in the Reception Area informing visitors of the current situation and ask anyone who is concerned to speak to the person in charge (Appendix 3). It is generally advisable to suggest that young children, pregnant women and anyone who is immunocompromised do not visit until the situation has resolved. Consideration should also be given to restricting visitors until the outbreak is over. Visitors should be made aware of and asked to wash their hands on entry and exit from the home (Appendix 5). There should be no cross over of staff between affected and unaffected residents. Non-essential services, ie hairdressing, should be postponed. Inform the CICN/Hospital Infection Control Team of any residents admitted to hospital up to 48 hours prior to the first resident becoming ill. If any resident(s) require emergency admission to hospital, inform the infection control team or ward so that appropriate precautions can be taken. You may be asked by the EHO to obtain samples of diarrhoea from symptomatic residents and staff as soon as possible after the onset of symptoms. Faecal sample pots and laboratory request forms can be obtained from Environmental Health. Do not submit formed stool specimens or specimens of vomit/urine. Complete a laboratory request form for each sample as advised by the EHO. Every laboratory form submitted must have an incident reference number recorded on it; The EHO will provide you with this number. Ensure that the patient/sample details are completed on the sample pot label. Record details of all samples submitted on the outbreak forms. See appendix 1 and 2. Environmental Health will inform you of the laboratory results when they are available. If there are any queries please do not contact the laboratory. MANAGER RATIONALE It is important to have accurate records in order to monitor the outbreak. To reduce airborne transfer of the virus and provide a safe environment for those residents unaffected by the infection. The decision to isolate will be influenced by the availability of facilities as well the physical condition of the area where isolation is to take place and the psychological well being of the resident. Staff will continue to excrete the virus for 48 hrs after symptoms have stopped. The home must be assured that they have taken steps to reduce the risk of infection to new or planned admissions and visitors who maybe susceptible to infection. Protect the most vulnerable in society and allows others to make an informed decision whether or not to visit (e.g. visitors with small children or who are employed in the catering industry etc.) To reduce the risk of cross infection to others. To alert the hospital of the patients contact with infected individuals and ensure necessary monitoring and precautions are maintained within the hospital setting. To ensure necessary precautions are instigated immediately upon the resident s admission to hospital. We are usually able to identify the cause of the outbreak from the information provided, but to be sure we may need to isolate the bacteria/virus from the faecal specimens. The likelihood of identifying the infective agent increases with the number of people sampled and the earlier after onset the samples are obtained. The infective agent is not easily isolated from these specimens. The lab cannot process the sample unless the form is completed correctly. This will ensure that all specimens relating to the outbreak can be identified and linked. The laboratory will not process unlabelled samples. It is important to have accurate records in order to monitor the outbreak. The laboratory will automatically notify Environmental Health when the results are available.

5 PAGE 5 ACTION You may be requested by Environmental Health to obtain samples of diarrhoea from symptomatic residents as soon as possible after the onset of symptoms. The EHO will advise the Home Manager on how to access sample pots and laboratory request forms etc. Please do not submit formed stools or specimens of vomit/urine. Complete a laboratory request form for each sample as advised by the EHO. Every laboratory form submitted must have an incident reference number recorded on it; The EHO will have provided your manager with this number. Ensure that the patient/sample details are completed on the sample pot label. Record details of all samples submitted on the outbreak form. See appendix 1 and 2. Environmental Health will inform you of the lab results when they are available. If there are any queries please do not contact the laboratory. Toileting can include the use of bedpans, bottles and commodes. Always use gloves and apron Cover bedpan etc. whilst in transit Discard excreta directly into bedpan washer/ macerator or toilet Reinforce the practice of good hand hygiene. Hands should be washed: On arrival for duty After any situation that involves direct client contact eg bathing, assisting to move, toileting etc. Before and after clinical procedures After bed making After removing gloves Before and after giving medication Before preparing, handling or eating food After handling contaminated laundry or waste After using the toilet After leaving a work area Post hand hygiene reminder notices around the care home (Appendix 4) Ensure that (CE marked) disposable gloves are worn when delivering direct care to all residents. Gloves must be changed after contact with every resident Upon completion of the task gloves should be removed inside the residents room and the hands washed and dried thoroughly. NURSING/HEALTHCARE STAFF RATIONALE We can guess the cause of outbreaks from the information you give us but to be sure we may need to isolate the bacteria/virus from faecal specimens. The likelihood of identifying the infective agent increases with the number of people sampled are obtained. The virus cannot be isolated from these specimens. The laboratory cannot process the sample unless the form is completed correctly. The laboratory will not process unlabelled samples. It is important to have accurate records in order to monitor the outbreak. The laboratory will automatically notify Environmental Health when the results are available. To reduce risk associated with the disposal of human waste. To reduce the risk of cross infection. Hand washing when done correctly is the single most effective way to prevent the spread of infection. (Appendix 4). To reduce the risk of hand contamination. Minimise risk of cross-infection to patients and staff. Organisms multiply quickly beneath gloved hands.

6 PAGE 6 ACTION Put on a disposable polythene apron when delivering direct care to all residents. NURSING/HEALTHCARE STAFF (Cont) RATIONALE A polythene apron is inexpensive, quick to put on and protects the front of the uniform which is the most likely area to come into contact with the resident. Polythene aprons should be removed upon completion of the task and not worn between residents. Wearing of masks All linen of symptomatic residents to be bagged in the individual s room. Soiled linen should be placed in a red alginate bag to remove the need for further handling of contaminated articles. Soiled linen must be bagged at source. Contaminated pillows should be laundered as infected linen unless they are covered with an impermeable cover Equipment and supplies in the resident s room to be kept for the sole use of the client. Only keep essential equipment in the room. Cleaning contaminated hard surfaces: It is vital that any physical evidence of illness is promptly and thoroughly cleaned up. Always wear protective clothing e.g. disposable gloves and aprons Vomit should be covered immediately with paper towels and cleaned up as quickly as possible Use paper wipe to absorb/remove visible soiling and dispose of as clinical waste Before disinfection surfaces must be washed using a detergent solution and dried with paper wipe Re-wash area using a diluted disinfectant solution e.g. Hypochlorite solution at 1,000 ppm strength (household bleach diluted with water to ) dependant on the strength of the product. Dispose of gloves, apron and cloths into waste bag Wash hands thoroughly Ventilate the area by opening the window(s) Staff designated to cleaning duties should not perform carer s duties. At the end of the outbreak a terminal clean must be undertaken. Prevent transferring viral particles outside the patient s environment. Masks are unnecessary and they can contribute to cross infection in these circumstances. To prevent environmental contamination. Equipment used regularly by the patient should be kept inside their room to prevent spread of infection. Prevent spread of infection. Prevent transferring viral particles outside the patient s environment. Prevent the release of airborne viral particles. Disinfectants cannot completely penetrate organic matter. Disinfectant solutions may damage fabrics and some plastics please refer to manufactures instructions. To eliminate airborne transfer of the virus within the home

7 PAGE 7 ACTION GENERAL CLEANING ADVICE RATIONALE Stock the hand basin with a suitable liquid soap preparation and paper towels for staff use. Linen and Clothing to be washed on hottest possible wash cycle the fabric will allow. Be mindful of woollen garments. For soiled bed linen the following should be adhered to wash at 65ºC for 10 minutes or 71ºC or above for 3 minutes. General environmental cleaning toilet areas frequency to be increased to four times a day for objects that are frequently handled e.g. All door handles including flush handles toilet door handles taps bath rails commodes toilet seats light switches, etc. (use disinfectant e.g. Household bleach diluted to ). Cleaning soiled contaminated hard surfaces: It is vital that any physical evidence of illness is promptly and thoroughly cleaned up Always wear protective clothing e.g. disposable gloves and aprons Vomit should be covered immediately with paper towels and cleaned up as quickly as possible Use paper wipe to absorb/remove visible soiling, and dispose of as clinical waste Before disinfection surfaces must be washed using a detergent solution and dried with paper wipe Re-wash area using a diluted disinfectant solution eg. Hypochlorite solution at 1,000 ppm strength (Household bleach diluted with water to ) dependant on the strength of the product. Dispose of gloves, apron and cloths into waste bag Wash hands thoroughly Ventilate the area by opening a window(s) Soiled contaminated fabrics/soft surfaces should: If removable should be bagged and sent for laundering as for linen. If fixed, wipe with a disposable wipe and wash area with a hot water and detergent solution then dry. Furniture and fittings should be damp dusted using a disposable cloth and detergent solution. A disinfectant hypochlorite solution at 1,000 ppm, dependant on the strength of the product, may be used on most hard surfaces. Carpeting It is recommended that an automated washer/extractor vacuum cleaner be used for deep cleaning of soiled carpeting (steam cleaning is different to washer/extractor ). Facilities for hand washing within the infected areas are essential for the containment of the outbreak. These temperatures are needed to achieve thermal disinfection. To minimise the risk of infection being spread from these surfaces as these areas may become recontaminated rapidly after clearing. Prevent spread of infection. Prevent the spread of airborne viral particles. Disinfectants cannot completely penetrate organic matter. Disinfectant solutions may damage fabrics and some plastics, please refer to manufacturers instructions. To eliminate airborne transfer of the virus within the home. To remove viral particles and prevent cross infection. Wiping of surfaces is the most effective way of removing contaminants. Virus can survival in carpet fibres for at least 12 days.

8 PAGE 8 CATERING STAFF ACTION Inform the EHO of any catering staff with symptoms just before or during the outbreak. It is always good practice to restrict access to the kitchen by care staff, this is particularly important during an outbreak. Environmental Health will be able to advise you about this. Retain menu details (including special diets) for the meals served to residents the week prior to the start of the outbreak. Also please provide details of any external functions attended by residents or other food brought into the home by residents. Advise Environmental Health if there are planned social events taking place during the outbreak where food will be provided for visitors e.g. parties, buffets. Environmental Health will advise you about these. All catering staff who have symptoms of diarrhoea, vomiting or nausea, must be excluded from duties until they have been free of symptoms for 48 hours and be requested to provide a specimen. RATIONALE It is important to have accurate information in order to investigate and monitor the outbreak. Care staff that are dealing with residents suffering from diarrhoea and vomiting can transfer the infective agent (bacteria/virus) via food if adequate precautions are not taken. It is important to have accurate information in order to investigate the cause of the outbreak. The infective agent (bacterial/virus) can be transferred through food if adequate precautions are not taken. To prevent contamination of food

9 PAGE 9 APPENDIX 1 Name of Care Home Photocopy as necessary Residents Affected Incident No: Name Date of Birth Unit or Floor Symptoms e.g. diarrhoea or vomiting Date and time of onset Date of recovery Date sampled submitted Results Additional Information

10 PAGE 10 APPENDIX 2 Name of Care Home Photocopy as necessary Staff Affected Incident No: Name Date of Birth Job Symptoms e.g. diarrhoea or vomiting Date and time of onset Date of recovery Date sampled submitted Results Additional Information

11 PAGE 11 APPENDIX 3 We are presently experiencing an outbreak of diarrhoea and vomiting within the care home. After seeking specialist advice it is recommended that visitors should refrain from entering at present unless absolutely necessary. In particular we would advise that children, pregnant women and those particularly vulnerable to infection do not visit at the present time. If you would like further information regarding this issue then please contact the home by telephone. As soon as this problem is deemed to be over, visiting will return to normal. Management and staff appreciate your help in this matter

12 PAGE 12 APPENDIX 4 Effective Hand Washing Technique Wet hands and forearms and apply soap using the following procedure, each step consisting of five strokes backwards and forwards. Palm to palm Right palm over left dorsum and left palm over right dorsum Palm to palm fingers interlaced Backs of fingers to opposing palms with fingers interlocked Rotational rubbing of right thumb clasped in left palm and vice versa Rotational rubbing, backwards and forwards, with clasped fingers right hand and vice versa Rinse thoroughly and dry well. Effective drying of hands after washing is important because wet surfaces transfer microorganisms more effectively than dry ones, and inadequately dried hands are prone to skin damage.

13 PAGE 13 APPENDIX 5 Please wash and dry your hands on entering and leaving the home Many thanks

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