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Clinical

Gastroenteritis, Infection Prevention and Control: Standard


Operating Procedure
Document Control Summary
Status:

Replacement.
Replaces: Policy for the Management of Gastroenteritis in
Healthcare

Version:
Author Title:
Owner/Title:
Approved by:
Ratified:
Related Trust Strategy
and/or Strategic Aims
Implementation Date:
Review Date:
Key Words:
Associated Policy or
Standard Operating
Procedures

v1.0

Date:

November 2015

Judy Carr - Lead Infection Prevention and Control Nurse


Kenny Laing - Deputy Director of Nursing
Policy and Procedures Committee

Date:

17/12/15

Policy and Procedures Committee

Date:

17/12/15

Provide high quality services, built on best known practice and


evaluated through clear process and outcome measures
December 2015
December 2018
Vomiting, diarrhoea
Infection Prevention Control and Decontamination Policy
Management of an Outbreak or other Infection Control Incidents
Hand decontamination SOP
Isolation SOP
Standard precautions SOP

Contents
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Introduction .............................................................................................................. 2
Purpose ..................................................................................................................... 3
Scope ........................................................................................................................ 3
Clinical Features, Signs and Symptoms of Norovirus ........................................... 3
Mode of Transmission ............................................................................................. 4
Identification and Reporting of a Suspected Outbreak.......................................... 4
Control Measures ..................................................................................................... 5
Patient Care .............................................................................................................. 5
Patient Movement in Hospital .................................................................................. 6
Discharge/Transfer of Patients ................................................................................ 6

Gastroenteritis, Infection Prevention and Control SOP/December 2015

11.
12.
13.
14.
15.
16.

Staff Movement in Hospital...................................................................................... 6


Visitors ...................................................................................................................... 7
Environmental Cleaning........................................................................................... 7
Deep Cleaning at end of Outbreak .......................................................................... 8
Process For Monitoring Compliance And Effectiveness ....................................... 8
References ................................................................................................................ 9

Change Control Amendment History


Version

Dates

Amendments

1. Introduction
In the UK, gastroenteritis causes a huge burden of disease in the community and hospitals
and is responsible for much time missed from work. Patients and/or staff with gastroenteritis
can infect other patients leading to healthcare associated outbreaks of diarrhoea and
vomiting. Strict infection prevention and control precautions are therefore necessary for
patients with symptoms suggestive of gastroenteritis.
Organisms that cause infectious diarrhoea are spread by the faecal/oral route. For an
individual to become infected the organism must be ingested and most commonly this will
result from unwashed and contaminated hands coming in contact with the mouth. It may also
occur via ingesting contaminated food.
It is important to consider all cases of diarrhoea and vomiting as potentially infectious until
appropriate investigations are completed.
Patients presenting with unexplained diarrhoea and / or vomiting Must be isolated in single
rooms. If this is not possible the Infection Prevention and Control (IPC) team should be
informed.
The IPC team should be contacted whenever there are two or more patients presenting with
unexplained diarrhoea and / or vomiting in a clinical setting.
In a healthcare setting it is important to distinguish between infectious and non-infectious
diarrhoea. Infective diarrhoea can be caused by both viral and bacterial pathogens.
Examples most commonly seen in healthcare settings include:
Viral causes:
Norovirus (previously known as Small round structured virus (SRSV) or
Norwalk virus)
Rota virus
Adenovirus
Bacterial causes:

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Gastroenteritis, Infection Prevention and Control SOP/December 2015

Clostridium difficile toxin (C.difficile) For further advice access trust policy
management of Clostridium Difficile
Campylobactor *
Salmonella.spp*
Shigella*
Escherichia coli*
Listeria*
staphylococcal enterotoxins
* see isolation SOP

for

Food Poisoning
In a healthcare setting it is also important to identify any case of diarrhoea that may have
resulted from suspected food poisoning. This is of particular relevance in areas where
service users may have access to external food sources e.g. take away outlets and / or
prepare their own food that is sourced from local shops. Further guidance can be found in
the trust protocol for take away food.
Food poisoning or suspected food poisoning is also notifiable, although not specifically listed
as a " notifiable disease". Further information can be found in the isolation policy regarding
notification.

2. Purpose
The Purpose of the SOP is to provide advice about the management of an outbreak of
gastroenteritis infection within the trust. The aim is to prevent cross infection and minimise
the disruption caused by ward closures.

3. Scope
This policy applies to healthcare personnel working within the trust. It also applies to private
contractors working on Trust premises including, locum and agency staff and volunteers.

4. Clinical Features, Signs and Symptoms of Norovirus


Norovirus is the most common cause of infectious gastroenteritis (diarrhoea and vomiting) in
England and Wales. Norovirus is the name given to a group of viruses previously known as
small round structured virus (SRSVs),Norwalk and Norwalklike virus .
In the general community, Norovirus is a common cause of sporadic cases and small
clusters of gastro-enteritis. Large outbreaks can occur in healthcare settings such as
hospitals and nursing homes, hotels and schools.
The incubation period for Norovirus associated gastroenteritis is usually between 15 48
hours .Symptoms may include

Sudden onset of vomiting


Watery non bloody diarrhoea *
Abdominal cramps
Nausea
Low grade fever

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Gastroenteritis, Infection Prevention and Control SOP/December 2015

Headache

The Illness is generally mild and people usually recover fully within 2-3 days. Infections can
occur at any age because immunity is not long lasting.
Definition of diarrhoea The passage of stool loose enough to take the shape of the
container used to sample it or as Bristol Stool Chart types 5-7 (DH, HPA 2009), see Bristol
stool form Chart (Associate document 5)

5. Mode of Transmission
Noroviruses are highly infectious and are primarily transmitted, via the faecal-oral route or
direct person to person spread.
The projectile nature of vomiting leads to widespread aerosol dissemination of virus particles
also leading to environmental contamination and subsequent indirect person-to-person
spread.

6. Identification and Reporting of a Suspected Outbreak


It is important to consider all cases of diarrhoea and vomiting as potentially infectious until
appropriate investigations are completed.
In the absence of laboratory confirmation, the following criteria can be used as a rough
indicator of a Norovirus outbreak:
1) average duration of illness of 12 to 60 hours
2) average incubation period of 24 to 48 hours
3) more than 50% of people with vomiting
4) no bacterial agent found.
5) Involvement of staff as well as patients.
If two or more patients present with symptoms of diarrhoea and or vomiting of unknown
cause ward staff should inform the IPC team immediately
Informing the Infection Prevention and Control Team
Monday - Friday (9am to 5pm):
When an outbreak / incident is suspected, the nurse / person in charge of the clinical area
must contact the IPC team. Even if the situation is unclear, the IPC team must be contacted.
The IPC team will assess the situation, and will inform the Consultant Microbiologist and
Director of Infection Prevention and Control. The decision will be made as to whether the
ward should be closed.
The Consultant Microbiologist will, if deemed necessary, inform the local Consultant in
Communicable Disease Control (CCDC).
Out of hours, Weekends or Public Holidays:

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Gastroenteritis, Infection Prevention and Control SOP/December 2015

The nurse / person in charge of the affected clinical area must contact the on call manager
without delay
The on-call manager must then assess the situation. This involves taking details of the
affected patients / staff and a history of the illness.
If an outbreak is suspected, or the situation is unclear, the on-call manager must then
contact the Consultant Microbiologist, via Queens Switchboard. A decision will then be made
as to whether the ward should be closed.
Contact telephone numbers (Associate document 6)
Once an outbreak or incident has been recognised within normal working hours, the
Consultant Microbiologist and Director of Infection Prevention and Control will be the
persons primarily responsible for action within the Trust.
Some outbreaks / incidents are of such a limited extent that the Consultant Microbiologist
and the IPC team can jointly deal with them. In such circumstances The Director of Infection
Prevention and Control and all other relevant managers will be kept informed of any
investigation and actions taken by the IPC Team. However, other outbreaks / incidents may
require the Outbreak Control Team (OCT) to be established. A decision whether an OCT is
required will be made jointly by the Consultant Microbiologist and Director of Infection
Prevention and Control, based on the individual circumstances of the incident.

7. Control Measures
Refer to the following trust policies

Management of an Outbreak or other Infection Control Incidents


Hand decontamination policy
Isolation policy
Standard precautions policy

The clinical area should use Outbreak information in Infection Prevention and Control Folder,
this includes; See associate documents

Outbreak of Infection-Daily Checklist for nurse in charge (Associate document 1)


Outbreak recoding sheet (Associate document 2)
Sign for ward entrance to alert visitors to outbreak (Associate document 3)
Isolation form (Associate document 4)
Bristol Stool form (Associate document 5)
Leaflets for Service users and Carers (Kept on ward, Contact IPC team for further
copies)

8. Patient Care
1. Isolate symptomatic patients in single rooms, en suite where possible .The door should
remain closed .If this is not possible please discuss with the IPC team
2. Isolation is required until the patient is 48 hours free of symptoms.

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3. Stool specimens should be obtained as soon as possible on all affected patients.


Detection of viruses is more likely the earlier the specimen is obtained after onset of
symptoms.
4. Staff should keep accurate documentation of all patients presenting with symptoms. See
stool chart (Associate document 5)
and outbreak recording form (Associate
document 2)
5. If communal toilets are being used ,separate toilets should be designated for affected
and non-affected patients
6. Staff should wear gloves and apron for contact with an affected patient or environment.
7. Nursing staff must ensure all patient equipment is frequently cleaned using detergent
and water
8. Wash hands with soap and water after contact with an affected patient or environment,
after removing gloves and apron.
9. The importance of good hand decontamination should be reinforced to staff, patients and
visitors; Leaflets are available from the Infection Control team.
NOTE Hands must be washed with liquid soap and water after any contact with the patient
or their environment who have symptoms of diarrhoea and or vomiting of known or unknown
cause .Alcohol hand rubs, alone are not effective against a number of organisms that cause
these symptoms including Norovirus

9. Patient Movement in Hospital


1. Avoid transfer to unaffected areas of hospital (unless medically urgent and after
consultation with ICT).
2. If asymptomatic patients must be moved to another ward, they should be moved to a
single room for at least 48 hours in the receiving ward.
3. If symptomatic patients must visit another department for investigations, this should
preferably be done at the end of the list/clinic and the receiving department must be
informed beforehand. Ward managers should also inform the Domestic Supervisor as
extra cleaning may be required in the receiving department.

10. Discharge/Transfer of Patients


This should be avoided during the duration of the outbreak .This is to prevent the risk of
cross infection to the receiving establishment , even if the patients are asymptomatic .If it
does occur the receiving establishment must be informed and the patient nursed in isolation
for 48 hours to ensure they are not affected. Staff must complete an Inter healthcare transfer
form (Associate document 7).
Patients awaiting discharge to their own home who are unaffected or have recovered may
be discharged.

11. Staff Movement in Hospital


1. Affected staff must be excluded from work until asymptomatic for 48 hours.

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2. Nursing staff and domestic staff working in an affected area should not move and work in
an unaffected area of the hospital during one shift
3. Between shifts uniforms must be changed
4. Agency Staff should not work in affected areas unless absolutely necessary.
5. Any staff member, who develops symptoms of diarrhoea /vomiting on duty, should leave
work immediately and report to the Occupational Health Department. If diarrhoea is
present, a faecal sample should be submitted to the Microbiology department.
6. Non-essential personnel should be excluded from the ward.
7. Personnel who visit several wards e.g. phlebotomist, pharmacist, physiotherapists etc.
should visit the ward last in their routine visits. If possible, a designated individual should
be assigned to that ward for the duration of the outbreak. These staff should also follow
the patient care guidelines above.

12. Visitors
1. Visitors with diarrhoea and/or vomiting should be advised not to visit the ward until
symptom free for 48 hours.
2. Children should be excluded from visiting, wherever possible.
3. Visitors should be restricted to a minimum. They must be informed that they may be
exposed to infection and must wash hands with soap and water on entry to the ward
and on leaving the ward.
4. Visitors do not need to wear aprons or gloves unless they are involved in patient
handling/care.

13. Environmental Cleaning


1. The frequency of routine ward, bathroom and toilet cleaning should be increased to three
times a day.
2. Fixtures and fittings in toilet areas should be cleaned with detergent and hot water using
a disposable cloth, then disinfected with 1000ppm hypochlorite solution.
3. Use freshly prepared 1000ppm hypochlorite solution to disinfect all environmental
surfaces after cleaning with detergent and water.
4. Spillages of vomit and faeces must be cleaned promptly, wearing disposable apron and
gloves. Paper towels should be used to soak up excess liquid and then transferred to
orange clinical waste bags together with any solid matter. The soiled area should be
cleaned with detergent and warm water using a disposable cloth. The area should then
be disinfected using a freshly prepared 1000ppm hypochlorite solution. Gloves and
aprons should be discarded and hands should be washed thoroughly with soap and
water.
5. All contaminated linen must be placed carefully into a red alginate bag placed inside a
red outer bag, without generating further aerosols. Contaminated pillows should be
discarded, unless they are covered with an impermeable cover. If this is the case, they
should be disinfected with 1000ppm hypochlorite solution.
6. Crockery/Cutlery should be washed routinely in the ward dishwasher or returned to the
main kitchen. These items should not be washed by hand.
7. All exposed food in the ward area must be discarded. Food items must not be left open
in the ward area.

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14. Deep Cleaning at end of Outbreak


1. The ward must be thoroughly cleaned at the end of the outbreak with detergent and
water.
2. Walls up to head height should be washed with detergent and water and then disinfected
with 1000ppm hypochlorite solution.
3. Horizontal surfaces should be disinfected with freshly prepared 1000ppm hypochlorite
solution after cleaning.
4. All bed-curtains must be changed prior to re-opening.
5. Carpets and soft furnishings should be cleaned with hot water and detergent, or steam
cleaned. Vacuum cleaning is not recommended.
6. All exposed fruit/ food items must be thrown away.
Reopening of Ward
A decision to reopen the ward will be made jointly by the Infection Prevention and Control
Nurse, the Consultant Microbiologist and Director of Infection Prevention and Control, based
on the individual circumstances of the incident.

15. Process for Monitoring Compliance and Effectiveness


This SOP will be reviewed three yearly or earlier in light of new national guidance or other
significant change in circumstances.
Compliance with this SOP will be monitored through the mechanisms detailed in the table
below. Where compliance is deemed to be insufficient and the assurance provided is limited
then remedial actions will be drawn together through an action plan. This progress against
the action plan will be monitored at the specified committee/group. The results of the annual
audit will be escalated to the appropriate committee/group where appropriate.
Aspect of compliance
or effectiveness being
monitored

Monitoring
method

Individual or
department
responsible
for the
monitoring

Appropriate use of SOP

Investigation
into
outbreaks

Infection
prevention
and control
team

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Frequency
of the
monitorin
g activity

Group/
Committee/
forum which
will receive
the
findings/mon
itoring report
As
Infection
appropriate Prevention
and Control
committee

Committee/
individual
responsible
for ensuring
that the
actions are
completed
Matrons and
Ward Managers

Gastroenteritis, Infection Prevention and Control SOP/December 2015

Organisations
expectations in relation
to staff training, as
identified in the training
needs analysis

Training
Reports

Learning and
Development
Department

Monthly

HRODE
Committee

HRODE
Committee

16. References
Chadwick et al. Management of hospital outbreaks of gastro-enteritis due to small round
structured viruses. J. Hosp. Infection. (2000); 45: 1-10.
Health Protection Agency (2004). Preventing person-to-person spread following
gastrointestinal infections: guidelines for public health physicians and Environmental
Health officers. HPA.
Available from: www.hpa.org.uk/cdph/issues/CDPHvol7/No4/guidelines2_4_04.pdf
(Last accessed 3rd September 2009)
Health Protection Agency (2004). Norovirus Outbreaks in England and
Wales. CDR Weekly. 14:47.
http://www.hpa.org.uk/cdr/archives/2004/cdr4704.pdf (Last accessed 3rd September
2009)
Health Protection Agency ( 2006). Norovirus frequently asked questions.
http://www.hpa.org.uk/infections/topics_az/norovirus/faq.htm (Last accessed 3rd
September 2009)
DH/HPA. Clostridium difficile infection: how to deal with the problem, 2009. Available
at: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1232006607827.(last accessed
15th December 2009)

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