Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities. August 2012

Transcription

1 Population Health Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities August 2012 Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 1

2 Contents Chapter 1 Introduction Aim Definitions Diarrhoea & vomiting outbreaks... 3 Chapter 2 Outbreak management Preparation for an outbreak Outbreak reporting Outbreak recording Role of Population Health in an outbreak Duty of care... 4 Chapter 3 Laboratory testing... 4 Chapter 4 Practical management Isolation Exclusion Staff or volunteers Residents Visitors Segregation... 6 Chapter 5 Cleaning of the environment Managing body fluid spillage Cleaning vomit and faeces Handling dirty linen... 7 Chapter 6 Hand hygiene and personal protective measures Hand hygiene Personal Protective Equipment (PPE) Disposable gloves Disposable plastic aprons Masks, visors and eye protection... 8 Chapter 5 End of the outbreak... 8 Appendix 1: Vomiting and diarrhoea causing organisms... 9 Appendix 2: Cleaning guidelines for bleach Appendix 3: Resident isolation alert Appendix 4: Visitor notification alert Appendix 5: Hand washing technique Appendix 6: Flowchart for diarrhoea & vomiting outbreak in a residential care facility Appendix 7: Diarrhoea & vomiting outbreak log sheet RESIDENTIAL CASES Appendix 8: Diarrhoea & vomiting outbreak log sheet STAFF CASES Appendix 9: Diarrhoea & vomiting outbreak management checklist References Population Health Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 2

3 Chapter 1 Introduction Population Health 1.1 Aim The purpose of this document is to provide a guideline for the management of diarrhoea & vomiting outbreaks, primarily for use by residential care facility staff. The principles could also be applied to any other institutional care setting. It is important that all establishments have their own policies and procedures based on evidence based guidelines. 1.2 Definitions An outbreak of diarrhoea & vomiting may be defined as two or more cases with similar symptoms in residents or staff linked together by time, place or person. Residential care managers are recommended to notify Population Health of an outbreak of diarrhoea & vomiting. As general practitioners may not be aware of linked cases and therefore unaware that an outbreak is occurring, they may not notify Population Health of cases. 1.3 Diarrhoea & vomiting outbreaks Residential care facilities are high risk environments for diarrhoea & vomiting outbreaks because of the close proximity of residents and communal living arrangements. Elderly residents are at particular risk due to their older age and high rate of chronic medical conditions. Prompt interventions are therefore important in diarrhoea & vomiting outbreak. The organisms that are responsible for diarrhoea & vomiting outbreaks are generally viral but can be bacterial and as a result symptoms vary in their severity and longevity. (Appendix 1) The principle method of controlling the outbreak is to reduce/restrict the transmission of the causative organism. The transmission can vary depending on the causative organism. Transmission routes can include all or any of the following: Food and water Hand to mouth (inadequate hand washing) Person to person (direct contact with an infected person) Aerosol/airborne (droplet spread such as coughing and sneezing) Symptoms will also vary depending on the causative organism; these will include any or all of the following: Vomiting Nausea Diarrhoea Stomach cramps Fevers Lethargy Chapter 2 Outbreak management 2.1 Preparation for an outbreak Ensure that infection control policies (i.e. illness policy/cleaning policy) are in place & sufficient supplies are always on hand such as soap, paper towels etc.. Develop a staff contingency plan, particularly for when staff coverage becomes low (less than 80 percent). This should address the varying levels of available staff during an outbreak due to illness. Workload will increase during an outbreak with the need to provide continued provision of care and full implementation of infection control procedures. Staffing plans must ensure that there are adequate nurse to patient ratios. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 3

4 2.2 Outbreak reporting Population Health As soon as an outbreak is suspected within the establishment, the person in charge should contact Population Health on and ask for the duty Health Protection Officer, or if after hours call the on call Health Protection Officer on Prompt notification and reporting of cases of suspected infectious diseases to Population Health is essential for the control of the outbreak and allow rapid investigation and monitoring of infection, and allows the investigation and control of its spread. Population Health will decide whether this is a true outbreak, will verify the diagnosis, and will initiate and help coordinate any necessary action with the residential care facility manager. Population Health will provide an outbreak number if norovirus testing is required. 2.3 Outbreak recording The importance of record keeping is essential, particularly in an outbreak. Records should be kept of cases, their symptoms, dates of onset of illness, whether stool samples have been taken and the area within the residential care facility that the ill person works or lives. The manager should complete the management checklist and log sheets for both staff and resident cases (See appendices 7, 8 and 9) as soon as possible and fax or to Population Health without delay (Fax: , health.protection@waikato.health.nz). This helps Population Health staff to determine a full picture of events as well as to liaise effectively with laboratories regarding any specimen collections for further tests where required. 2.4 Role of Population Health in an outbreak During an outbreak in a residential care facility, Population Health can assist the facility care manager by: Confirming that an outbreak is occurring Verifying the nature and extent of the outbreak Identify positive causative agents, source and mode of transmission of the illness Consulting on control measures and laboratory investigation Inspecting the facility, or part if the facility as necessary Assisting in coordinating stool specimens and suspect foods for prompt laboratory analysis Communicating laboratory results to the facility Consulting with the facility Infection Control coordinator as needed 2.5 Duty of care The owner / manager has a duty of care to protect staff and residents. Therefore, policies and procedures must be adhered to in order to prevent the spread of disease. When the manager is not on duty, the elected person in charge will take responsibility. Everyone has a duty of care to protect themselves and others. Therefore, they must disclose relevant information such as symptoms etc. and take the necessary action. Adherence by everyone to policies, record keeping, hand washing and cleaning will minimise the transmission of the organisms. The person in charge has a duty to also ensure that all clinical/hazardous waste is correctly bagged, sealed, tagged and stored before collection for incineration/alternative treatment as is appropriate. Chapter 3 Laboratory testing Laboratory testing is required during an outbreak to determine what the causative organism is, and aide in identifying the possible source. Several people meeting the case definition should have laboratory tests performed. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 4

5 Population Health When to collect specimens? Early in the course of the illness if possible. For many organisms, the greater the likelihood of laboratory identification is from specimens collected within the first two days of illness. How to store? Store specimens at deg C. If specimens are collected late in the day or during the weekend and delivery to the laboratory will be delayed, then store under refrigeration. However in an outbreak setting best results are obtained from specimens tested soon after collection. How many specimens to collect? Population Health will notify you of how many samples are required however no more than four specimens from different clients are normally required to confirm the source of the outbreak. How does the residential facility find out the results? Population Health will phone the facility as soon as results are available from the laboratory. Population Health will provide an outbreak number if norovirus testing is required. Chapter 4 Practical management The principle method of controlling the outbreak is to remove the source and to restrict the transmission of the diarrhoea and vomiting organism. The most important areas of outbreak management are: 1. The isolation, exclusion and segregation of affected residents and staff 2. Hand hygiene and personal protection equipment 3. Cleaning the environment Isolation Isolating symptomatic people from well people is important. Isolation means having your own facilities and cleaning equipment, and being kept separate from well people in a single room with ensuite facilities. If this is not feasible, separate areas, including separate toilet areas and cleaning equipment, should be designated for sole use by those people that are unwell. It is very important that strict isolation is carried out. The symptomatic person should be isolated from residents and visitors until 48 hrs after their last episode of diarrhoea or vomiting. Signs stating that the person is in isolation should be posted on the door of their room. Non-essential staff should be restricted from entering the isolation rooms (Appendix 3). If a large number of residents are unwell or the illness is severe, consideration should be given to keeping non-ill residents in their rooms for the first 72 hours of the outbreak, because some of them may be incubating the infection and be infectious themselves. Movement of residents out of isolation rooms should only be for essential purposes. No residents should be transferred if they are unwell with symptoms, unless transferring for medical care. When transferring a case for hospital care, the hospital should be informed of the situation so they can make arrangements for the necessary precautions to be implemented. Consider rescheduling any non-urgent medical appointments that were made before the outbreak. 4.2 Exclusion Staff or volunteers It is essential that all symptomatic staff or volunteers, including temporary or agency staff are excluded from the centre. Staff should call in sick if unwell and should be sent home immediately if they become sick at work. It is the responsibility of the person in charge to check the health of anyone arriving at the centre. Staff need to stay at home until well. This is usually three to four days after symptoms start, but may be up to one week. They must remain off work for at least 24 hours after their last episode of diarrhoea and vomiting. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 5

6 Population Health Symptomatic staff should also be excluded from working in any other health care facility. Asymptomatic staff may work in other facilities, but should wait three days from the time they last worked at the outbreak residential care facility prior to working in any other centre. This is to ensure that they are not incubating the diarrhoea and vomiting organism Residents The residents in nursing and residential homes obviously cannot be excluded and therefore very strict isolation and segregation must be observed. No admissions of new residents should occur during the outbreak. The return from hospital of residents who meet the case definition can be permitted provided appropriate care can be provided. The return of residents from hospital that are not known cases is generally not recommended during an outbreak, unless measures can be enforced to prevent transmission. Factors to be considered include availability of adequate staff to care for the readmitted resident Visitors A sign should be placed at the entrance to the residential care facility to indicate to visitors that there is an outbreak. (Appendix 4) Visitors should be asked about symptoms on arrival, and all who are unwell should be excluded from visiting the residential care facility. Visitors who are well should be advised of the risk of exposure to the organism from visiting during an outbreak. Visits to multiple residents should be restricted. Visitors must comply with all isolation procedures and should be assisted with when putting on and removing personal protective equipment to ensure it is properly used and to ensure hand hygiene is thorough. 4.3 Segregation Segregation is sometimes necessary in an outbreak where a large group of people use the building. Cohort nursing is the grouping of symptomatic residents and nursing them all in one area. It is very important that the symptomatic and well people are kept strictly apart. Staff should be specifically designated to work in one area and no transfers/mixing of residents from different areas should occur. This will help reduce the transmission of the organism and stop the spread of the outbreak. Chapter 5 Cleaning of the environment It is very important that there is a strict cleaning regime in the building during the outbreak, using clean disposable cloths, dedicated mops/ buckets, hot water and diluted bleach in communal areas. (Appendix 2) The building should be cleaned at least twice daily during an outbreak and any surface that becomes visibly soiled should be cleaned immediately. Particular attention should focus on commonly touched surfaces. This should include washrooms, handrails, tables, doorknobs and lift buttons. Both bacteria & viruses are inactivated by 70% alcohol and by 1% chlorine. Surfaces can be cleaned using standard disinfectants such as bleach, which is cheap and effective. Cleaning of surfaces with a neutral detergent followed by a disinfectant containing bleach or alcohol is recommended. The initial cleaning with detergent is important as bleach requires a surface free from dirt to work effectively. Allow an interval of at least 30 minutes after wiping surfaces with bleach solution before resuming use of that space, to allow enough time to kill any potential pathogens. Please refer to the cleaning guidelines for bleach in appendix 2. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 6

7 5.1 Managing body fluid spillage Population Health Body fluids can contain a high concentration of pathogens, which must be made safe as soon as possible after the spillage has occurred. Clearing body fluid spillages may expose the healthcare worker to pathogenic organisms and every care must be taken to ensure the member of staff is protected by the appropriate use of protective clothing. The rest home should have a spillage kit available for use in clearing spills. Staff should be aware of the contents of the kit and trained in its use and in the proper management of biohazard and body fluid spillages Cleaning vomit and faeces People, who clean up vomit or faeces, should minimise the risk of infection to themselves and others by: Wearing disposable gloves, and a plastic disposable apron Using paper towels to soak up excess liquid. Transfer these and any solid matter directly into a plastic garbage bag Clean the soiled area with detergent and water, using a single use cloth Disinfect the contaminated area with a suitable detergent solution (appendix 2) Deposit disposable gloves and aprons into a garbage bag Wash hands thoroughly using soap and warm running water for at least 20 seconds (appendix 5) 5.2 Handling dirty linen All dirty linen must be handled with care with special attention paid to the potential spread of the vomiting and diarrhoea organism. Plastic aprons and suitable gloves should be worn for handling dirty or contaminated clothing and linen. Gloves in the laundry should meet the same standards as gloves used for other caring activities because of the potential exposure to body fluids. All dirty or potentially contaminated clothing and linen should be placed in designated and labelled lined linen bags for laundering. Contaminated linens, clothes, towels, cloths etc., should be washed in the hottest water available and detergent using the maximum cycle length, and then machine dried on the hot cycle. Chapter 6 Hand hygiene and personal protective measures 6.1 Hand hygiene Hand hygiene is vital to prevent person to person transmission and should be actively encouraged and witnessed by management as occurring adequately by staff and clients. Hand washing by staff should occur both before and after providing care to all residents. Hands should also be washed before eating, after coughing or sneezing and after going to the toilet. Hands must be washed with soap and warm water for 15 to 20 seconds and then dried thoroughly, preferably with disposable hand towels. Alternatively if water be not available then antiseptic hand gel may be used for 15 to 20 seconds if the hands are not visibly soiled. All people arriving, including visitors to the residential care facility, should be asked to use hand gel before entry to the residential care facility and after leaving each residents room. 6.2 Personal Protective Equipment (PPE) Disposable gloves Disposable gloves are required when contact with body fluids is anticipated and should be for single use and wellfitting. Washing gloves rather than changing them is not safe and therefore not recommended. Hands should always be decontaminated following removal of gloves. Sensitivity to natural rubber latex in patients, carers and healthcare personnel must be documented, and alternatives to natural rubber latex gloves must be available. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 7

8 Gloves are not a substitute for hand hygiene. Population Health Gloves must be discarded after each care activity for which they were worn in order to prevent the transmission of micro-organisms to other sites in that individual or to other residents Disposable plastic aprons These should be worn whenever there is a risk of contaminating clothing with body fluids, or when a resident has a known infection. A disposable plastic apron should also be worn during direct patient care, bed-making, or when decontaminating equipment. The apron should be worn as a single-use item, for one procedure or episode of patient care, and then discarded as clinical waste as soon as the intended task is completed. Hands should be washed following this activity. Aprons must be stored so that they do not accumulate dust that can act as a reservoir for infection Masks, visors and eye protection It is rare that such protection is necessary in a residential care facility, however, such protective equipment should be stored in case of an emergency or when a procedure is likely to cause exposure to splashes of body fluids into the eyes, face or mouth. This protection could be recommended by infection control personnel if a communicable disease is being suspected.. Chapter 5 End of the outbreak The Medical Officer of Health will decide when the outbreak has ended. The diarrhoea and vomiting outbreak would normally declared over if no new cases have occurred in eight days from the onset of symptoms of the last case. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 8

9 Appendix 1: Vomiting and diarrhoea causing organisms Population Health Disease or causative organism Diarrhoeal illness (undiagnosed) Campylobacter spp. Incubation period Unknown 1-10 days Usually 3-5 days Mode of Transmission Hand to mouth Food Airborne Food raw poultry Hand to mouth Pet faeces Clostridium difficile Unknown Hand to mouth Environmental contamination Cryptosporidium spp. Giardia lamblia Viral gastroenteritis (undiagnosed) 1-12 days Usually 7 days 3-25 days Usually 7-10 days Unknown Water Hand to mouth Water Hand to mouth Hand to mouth Droplet Norovirus Unknown Hand to mouth Droplet Period of infectivity Depends on organism but usually until 48 hours after diarrhoea has stopped While diarrhoea persists While diarrhoea persists While diarrhoea persists Duration of Symptoms Varies 2-5days Infection control Precautions Single room Separate toilet Single room if incontinent Separate toilet Single room Separate toilet Single room Separate toilet Until treated Single room if incontinent Separate toilet Variable. May be several days after symptoms resolve Up to 48 hours after symptoms resolve Single room Separate toilet hours Single room Separate toilet Treatment of Linen Treat as infected Treat as infected Treat as infected Notes Food borne infections can be incubated anywhere from a few hours to up to 24 hours after consumption All pets in contact with residents should be examined by vet Follows treatment with antibiotics. Likely to cause outbreaks Notify Population Health Yes If two or more cases occur Yes (as potential food poisoning) Yes Treat as infected Yes Treat as infected Yes Treat as infected Treat as infected Very likely to cause outbreaks Very likely to cause outbreaks Yes If two or more cases occur Yes Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 9

10 Disease or causative organism Incubation Period Mode of Transmission Rotavirus Unknown Hand to mouth Droplet Escherichia coli Including verotoxin producing E. coli (VTEC) 2-10 days Food Hand to mouth Period of infectivity Variable, but unlikely to infect others 48 hours after diarrhoea stops unless poor hygiene/incontinent Duration of symptoms Up to 48 hours after symptoms resolve Typically less than a week Infection control Precautions Treatment of Linen 4-6 days Single room Separate toilet Single room until 48 hours after diarrhoea stops Separate toilet Treat as infected Notes Treat as infected Retain food samples Population Health Notify Population Health Very likely to cause outbreaks Yes Salmonella spp. Shigella spp. Bacillus cereus food poisoning Clostridial food Poisoning (C.perfringens) 6-72 hours Usually hours 1-3 days Usually hours hours when vomiting predominant symptom & 6-24 hours for diarrhoea as predominant symptom 6-24 hours Usually hours Food Hand to mouth Hand to mouth Water or food contaminated by infected water Variable, but unlikely to infect others 48 hours after diarrhoea stops unless poor hygiene/incontinent Variable, but unlikely to infect others 48 hours after diarrhoea stops unless poor hygiene/incontinent Several days to several weeks Food Not infectious Usually 24hours Single room until 48 hours after diarrhoea stops Separate toilet 4-7 days Single room until 48 hours after diarrhoea stops Separate toilet Treat as infected Treat as infected Retain food samples Organism can be carried in stools for weeks or months after infection Very likely to cause outbreaks Disease or Incubation Mode of Period of Duration of Infection control Treatment of Notes Notify causative Period Transmission Infectivity Symptoms Precautions Linen Population Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 10 None No special treatment Food Not infectious 1 day or less None No special treatment Retain food samples Toxin formed in gut after ingestion Retain food Yes Yes Yes Yes

11 organism Staphylococcal food poisoning 30 minutes to 8 hours Usually 2-4 hours Food Not infectious Usually hours None No special treatment Retain food samples Food contamination from infected fingers, eyes, etc. of food handlers Population Health Health Yes Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 11

12 Appendix 2: Cleaning guidelines for bleach Population Health Household bleach is a high level disinfectant capable of killing viruses and bacteria. In order to work properly bleach disinfectant needs: Enough time to kill at least 10 minutes contact time is required Sufficient strength or concentration A surface free of organic material, dirt and dust When cleaning, wear non-sterile disposable gloves. Supermarket bleaches (e.g. Janola, White Magic, Domestos) are suitable and cheap disinfectants to use to wipe down surfaces that are regularly used by others. Supermarket bleaches are sold in different strengths, usually 2-5% sodium hypochlorite solution. The strength is written on the label. The recommended concentration of bleach disinfectant is 1000ppm (0.1%) hypochlorite. To achieve this, the following table provides a guide to diluting supermarket bleach. Original strength of bleach Disinfectant recipe In a standard 10 % ppm Parts of bleach Parts of water litre bucket 1 10, mls 2 20, mls 3 30, mls 4 40, mls 5 50, mls Instructions for use of bleach Make the bleach solution up fresh each day and discard any leftovers after 24 hours. Keep diluted bleach covered, protected from sunlight and heat, in a dark container (if possible) and keep out of reach of children. A spray bottle is an effective way to use bleach solution. Spray the bleach solution on to hard surfaces for 10 minutes before wiping off. If items are being placed into a bleach solution then it is recommended that the item is soaked for 30 minutes. Once an item or surface is disinfected, allow it to air dry. During wet cleaning, cleaning solutions and buckets/cloths can soon become contaminated. Clean less heavily contaminated areas first and change cleaning solutions, cleaning cloths and if possible mop heads frequently. Ideally, disposable cloths should be used for cleaning surfaces and disposed of after use. If reusable cloths are used, soak in bleach solution and allow to air dry. All gloves worn during cleaning should be removed and discarded. Those carrying out cleaning should avoid touching their faces with gloved or unwashed hands. Practice thorough hand hygiene immediately after gloves are removed. Wash hands for 20 seconds using warm, soapy water. Dry for at least 20 seconds using paper towels or 45 seconds if using a hand dryer. If you are using an alcohol based sanitizer, ensure that it has an isopropyl or ethyl alcohol concentration of 70% w/w. If there is visible build up of organic material or dirt on hands, full hand hygiene using soap and water is required. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 12

13 Appendix 3: Resident isolation alert Population Health PLEASE DO NOT ENTER THIS ROOM BEFORE SPEAKING TO THE NURSE IN CHARGE PRECAUTIONS: Gloves Apron Prior to leaving room, please remove all protective clothing and wash hands or clean with Alcohol gel immediately Please do not visit this resident if you are unwell Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 13

14 Appendix 4: Visitor notification alert Population Health ATTENTION TO ALL VISITORS We presently have a number of unwell residents with diarrhoea and vomiting. Please do not visit if you are also currently feeling unwell. We ask that you keep visitor numbers to a minimum until further notice. Please wash your hands when you first arrive and just before you leave. All precautions have been taken in the facility to reduce any further spread of the infection and we appreciate your support and cooperation For further information, please contact the Registered Nurse in charge. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 14

15 Appendix 5: Hand washing technique Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 15

16 Appendix 6: Flowchart for diarrhoea & vomiting outbreak in a residential care facility Diarrhoea & Vomiting (D&V) Outbreak Suspected Two or more cases of diarrhoea & vomiting linked by time place or person Contact Population Health Ask for the duty Health Protection Officer. After Hours call Begin completing log forms (Appendix 7 & 8) Begin completing management check l STAFF VISITORS RESIDENTS INFECTION CONTROL PROCEDURES ADMISSIONS AND TRANSFERS Exclude unwell staff from work until 48hours after last episode of D&V Ensure signage is in place to warn visitors Symptoms of D&V Isolate residents until 48hours has passed since last episode of D&V Well Consider cohort nursing ie: different staff treating well and unwell residents Residents who were sent to hospital with D&V and now returning New residents In hospital prior to outbreak with no D&V Symptoms of D&V Well Re-admit as per the residents section of this flowchart. Exclude from visiting Restrict visiting to a single friend or relative. Must adhere to infection control measures Arrange medical assessment Laboratory testing if advised by the Population Health. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 16 Outbreak not under control Not for admission Outbreak over Admit Outbreak not under control Readmission not recommended

17 Appendix 7: Diarrhoea & vomiting outbreak log sheet RESIDENTIAL CASES Please fax together with Management Checklist to Population Health Surname (Print) First Name DOB & NHI Room and Location GP Details Sex Date of Onset Symptoms Duration of Symptoms Stool Sample (date) Outcome Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 17

18 Appendix 8: Diarrhoea & vomiting outbreak log sheet STAFF CASES Please fax together with Management Checklist to Population Health Surname (Print) First Name Staff Title DOB & NHI GP Details Sex Date of Onset Symptoms Duration of Symptoms Stool Sample (date) Outcome Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 18

19 Appendix 9: Diarrhoea & vomiting outbreak management checklist (Please fax together with log sheets to Population Health ) Date Completed: Checklist Completed By (Print Name): Name & Tel No of Institution: Type of Institution: Name of Manager: History of outbreak: Action taken by institution (e.g. Isolation time, hand washing etc): Environmental protection measures Yes No Comments Correct hand hygiene protocols are in place and maintained with constant supplies of liquid soap and paper towels readily available IMMEDIATELY Ensure appropriate personal protective measures are worn during contact with cases and/or the environment and that constant supplies are readily available. (i.e. disposable latex gloves, aprons and masks) IMMEDIATELY Systems in place for the safe disposal of PPE and hand towels following hand washing (e.g. covered bins with liners) IMMEDIATELY Cleaning and disinfection of vomit and faeces spillages promptly as per local policy IMMEDIATELY Ensure the use of freshly prepared 0.1% (1000 ppm) chlorine releasing agent to disinfect hard surfaces (after cleaning with neutral detergent). Maintaining frequent cleaning of all areas at least twice daily, using appropriate cleaning products. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 19

20 Make certain that Infected clothing/ linen is segregated into linen laundry bags and laundered as per guidelines Steam clean carpets/furniture as needed Provide notices for visitors specifying restrictions imposed and the risks of visiting during an outbreak. Emphasise hand hygiene and support the use of PPE as required Medical treatment Yes No Comments Medical assessment arranged for all unwell residents IMMEDIATELY Stool samples collected and sent, when appropriate and as arranged by the GP or Population Health. (Outbreak number required from Population Health for norovirus testing) Exclusion/Isolation/Segregation Yes No Comments Isolation of symptomatic individuals, where possible IMMEDIATELY Dedicated toilet/ablution facility and equipment IMMEDIATELY Cohort nursing of symptomatic individuals, where possible IMMEDIATELY Exclusion of affected staff from the ward immediately and until asymptomatic for 48hrs IMMEDIATELY Admissions, discharges & transfers suspended where possible Closure of ward to new admissions Avoid transfer to unaffected wards, departments or institutions (Unless medically indicated and after consultation with ICT to avoid spread to other areas) Check if staff work elsewhere (restrict) and that all staff are well (including agency). Exclude if unwell (see below) Exclusion of non-essential personnel from the residential care facility Administration and documentation Yes No Comments Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 20

21 Notify the Medical Officer of Health / Population Health IMMEDIATELY Complete and fax log sheets. Include DOB/ NHI and GP. IMMEDIATELY Accurate & timely documentation Document the frequency of routine ward, bathroom and toilet cleaning. (maintain an increased frequency of usual practice and also the cleaning of frequently touched areas) Review outbreak including prevention and management. References Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 21

22 1. Department of Health (2006) Infection control guidance for care homes [Online] [Cited 08/12/10] Available from World Wide Web: 2. Heymann, David L. Control of Communicable Diseases Manual, 19 th Edition, 2008, American Public Health Association 3. Waikato District Health Board, Population Health, Influenza Guidelines for Rest Care Facilities, 2010 (unpublished internal document), Waikato District Health Board 4. Waikato District Health Board, Intranet, Infection Control, Infectious Diseases and Organisms, Management Of, 2009, (internal document), Waikato District Health Board 5. Fraser Health. Managing Outbreaks of Gastroenteritis in Residential Care Facilities, 2009 [Online] [Cited 08/12/10]: 6. Ministry of Health New Zealand. Intranet, Guidelines for the Management of Norovirus Outbreaks in Hospitals and Elderly care Institutions, 2009 [Online] [Cited 20/12/10] 7. Public Health Western Australia. Guidelines for the management of outbreaks of gastroenteritis in residential care facilities, 2008 [Online] [Cited 01/02/11] 8. Auckland Regional Public Health Service. Advice for residential institutions and early childhood education centres on managing cases of novel influenza A (HINI) 09, 2009, Auckland: Auckland Regional Public Health Service 9. Images accessed from Google Images. Guidelines for the control of diarrhoea and vomiting outbreaks in residential care facilities 22