Joint Outbreaks of Suspected or Confirmed Norovirus Policy - V1.1 November 2021
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Document Reference Code: (to be added by the Policy Coordinator)
Joint Outbreaks of Suspected or
Confirmed Norovirus Policy
V1.1
November 2021Document Reference Code: (to be added by the Policy Coordinator)
CFT Governance Information
Title: Joint Outbreaks of Suspected or Confirmed Norovirus Policy V1.1
This policy has been developed to provide a practical document to
Purpose:
equip all healthcare staff at RCHT/CFT with the necessary information
on the recognition, management and treatment of Norovirus.
This policy applies to all staff working for or on behalf of the Royal
Applicable to: Cornwall Hospitals NHS Trust and Cornwall Partnership NHS
Foundation Trust, including volunteer, temporary, locum, bank, agency
and contracted staff
Document Definition: Policy
Document Author: Integrated Infection Prevention and Control Team (IPC)
Supporting CFT/RCHT Infection Prevention and Control Committee
Committee Name Louise Dickinson, Deputy Director of Nursing (Quality Safety & Innovation)
and Chair: and Director Infection Prevention & Control
Freedom of This document can be released
Information:
Key Words: Norovirus, Gastroenteritis, Diarrhoea, Vomiting, D&V, Virus, Noro,
(to assist search Outbreak
engine)
Ratified by and Date: (Name of the Executive Director to be added by the Policy Coordinator)
(Date to be added by the Policy Coordinator)
Review Date: (Date to be added by the Policy Coordinator)
6 months prior to the expiry date
Expiry Date: (Date to be added by the Policy Coordinator)
3 years after ratification unless there are any changes in legislation or
changes in NICE Guidance / National Standards
Document library (To be added by the Policy Coordinator)
location:
Related PHE (2012) Guidelines for the management of norovirus outbreaks in acute and
legislation and community health and social care settings
national Coia et al (2013) Guidance on the use of respiratory and facial protection
guidance: equipment. Journal of Hospital Infection 85, 170 – 182
Great Britain. Department of Health and Social Care (DHSC) (2015) The Health
and Social Care Act 2008: Code of Practice for health and adult social care on
the prevention and control of infections and related guidance. Updated July
2015. Available at: https://www.gov.uk/government/publications/the-health-and-
social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-
infections-and-related-guidance
Department of Health (2003) Winning Ways: working together to reduce
healthcare associated infection in England. London: Department of Health.
Haill, C. F., Newell, P., Ford, C., Whitley, M., Cox, J., Wallis, M., Best, Jenks, P.
J. (2012) ‘Compartmentalisation of wards to cohort symptomatic patients at the
Joint Outbreaks of Suspected or Confirmed Norovirus Policy V1.1
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beginning and end of norovirus outbreaks’, Journal of Hospital Infection, 82 (1)
pp. 30-35.
Health Protection Agency (2007) Guidance for the Management of Norovirus
Infection in Cruise Ships. London: HPA
Health and Safety Executive (HSE) (2015) Personal Protective Equipment at
Work (Third Edition): Personal Protective Equipment at Work Regulations 1992.
Available at: https://www.hse.gov.uk/pubns/books/l25.htm
Lopman, B., Reacher, M. H., Vipond, I. B., Hill, D., Perry, C., Halladay, T., Brown,
D. W., Edmunds, W. J. and Sarangi, J. (2004) ‘Epidemiology and cost of
nosocomial gastroenteritis, Avon, England’, Emerging Infectious Diseases, 10
(10) pp. 1827-1834.
Lopman B., Reacher, M. H, Vipond, I. B., Sangari, J. and Brown, D. W. G. (2004)
‘Clinical manifestation of Norovirus gastroenteritis in healthcare settings’, Clinical
Infectious Disease. 39 (3) pp. 318- 24.
Loveday, H. P., Wilson, J. A., Pratt, R. J., Golsorkhi, M., Tingle, A., Bak, A.,
Browne, J., Prieto, J., and Wilcox, M. (2014) ‘epic 3: National Evidence-Based
Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in
England’, Journal of Hospital Infection, 86, pp. S1-S70.
NHS England and NHS Improvement – South West (2020) South West
Regional Healthcare Setting Communicable Disease Outbreak Framework.
Norovirus Working Party (NWP) (2012) Guidelines for the management of
norovirus outbreaks in acute and community health and social care settings.
Public Health England (2020) Recommendations for the Public Health
Management of Gastrointestinal Infections 2019: Principles and Practice. London:
PHE.
Public Health England (2019) Hospital Norovirus Outbreak Reporting System:
User Guidance. London: PHE.
Public Health England (2016) Norovirus Toolkit
Public Health England (2014) Communicable Disease Outbreak Management:
Operational Guidance. London: PHE.
Public Health England (2013) Updated guidance on the management and
treatment of Clostridium Difficile Infection. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/att
achment_data/file/321891/Clostridium_difficile_management_and_treatment.pdf
Associated Cornwall & Isles of Scilly Health & Social Care Whole System Norovirus plan
Trust Policies Infection Prevention & Control Policies
and Documents: Cleaning Strategy, Manual & Policy
Decontamination Policy
Waste Management Policy
Linen/Laundry Policy
Clinical Record Keeping Policy
Standard Precautions Policy
Hand Hygiene Policy
Personal Protective Equipment Policy
Management of Outbreaks Policy
Management of Diarrhoea/Gastroenteritis Policy
Patient Movement Policy
Equality Impact The Equality Impact Assessment Form was completed on 04/04/2021
Assessment:
In line with the Public Sector Equality Duty, every procedural document will be
screened by the person responsible for its development, to consider whether
there is an equality dimension or whether any adjustments are necessary to
Joint Outbreaks of Suspected or Confirmed Norovirus Policy V1.1
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comply with the duty to promote equality and diversity. This should involve
consultation with stakeholders appropriate to the aims of the individual document.
The equality screening process and any wider impact assessment should be
recorded within the document using the heading “Equality Impact Assessment”.
(The organisation aims to design and implement services, policies and measures
that meet the diverse needs of our service, population and workforce, ensuring
that none are placed at a disadvantage over others. The Equality Impact
Assessment Tool is designed to help you consider the needs and assess the
impact of your document.)
Training All staff are required to have a working knowledge of this policy and the action
Requirements: cards relevant to their role.
Norovirus toolbox briefings will be held in November each year. These are
available to all healthcare staff. Records of attendance at the Norovirus toolbox
briefings will be forwarded to the Education and Training/Learning and
Development Department.
The organisation trains staff in line with the requirements set out in its training
needs analysis and published in its Corporate Curriculum.
Training which is categorised as statutory or essential must be completed in line
with the training needs analysis and Corporate Curriculum.
Compliance with statutory and essential training is monitored through the
Learning and Development team with monthly manager’s reports and staff
individual training records twice yearly. Training reports are also submitted
quarterly through the Trust Quality and Governance Committee Meeting.
Staff failing to complete this training will be accountable and could be subject to
disciplinary action.
Monitoring Discussed at the infection Prevention and Control Committee
Arrangements:
Implementation: The policy will be included in the Trust’s Document Library.
Staff will be made aware of the policy through local induction.
Version Control
Version Date Author Page No. Changes
V1.0 April 2021 Mandy May (CFT All - new Full review including integration of both
IPAC nurse team policy Cornwall Partnership NHS Foundation
lead) / Laura template Trust and Royal Cornwall Hospitals NHS
Ludman Trust policies. Review includes
(RCHT/CFT consultation. Reformatted in new
IPAC specialist temporary joint RCHT/CFT policy
nurse) template.
V1.1 October 2021 Laura Ludman 1, 5, 68, Added ‘Joint’ to Policy title.
IPAC Nurse 69 Updated flow chart – removed ‘is
Specialist Norovirus suspected’ option.
Added Appendix 20 and 21
This document Replaces:
Outbreaks of Suspected or Confirmed Norovirus Policy V1.0
Joint Outbreaks of Suspected or Confirmed Norovirus Policy V1.1
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Summary
Signs and Symptoms of Norovirus
The average incubation period for norovirus associated gastroenteritis is 12-62 hours (PHE
2019).
The illness is characterized by a sudden acute onset of:
• Vomiting (this is the predominant symptom, often projectile, and is seen in 50% of cases,
however, clusters can occur where vomiting is infrequent or absent altogether).
• Watery diarrhoea and abdominal cramps
• Nausea
• In addition headache, myalgia, fever and malaise are common.
• Some or all of the above symptoms may be present.
Patient has developed sudden onset Patient has developed sudden
watery diarrhoea and abdominal onset vomiting-often projectile
cramps.
Complete diarrhoea risk assessment tool
See Nerve Centre/Rio for on-line version
Is infective cause suspected?
NO YES
Isolation not required
• Isolate patient/client/service-user in a single-
occupancy room on the same ward
• Obtain stool specimen if patient has diarrhoea Isolate patient in
side room
• Close the bay (if symptoms commenced within a bay)
Complete terminal
• Inform IPC team/site co-ordinators of the closed clean of bed space
area(s)
• To determine the need to keep the bay closed,
Table of Contents
prompt review of the situation is required by:
▪ In hours – IPC team, Nurse in charge/Ward
leader/Matron, consultant/medical team
▪ Out of hours – RCHT Site Coordinator/CFT
On-call Manager, On-call Microbiologist,
Consultant/senior doctor/on call doctor
• Inform the Domestic Services team applicable to the
location to commence enhanced cleaning
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Table of Contents
CFT Governance Information............................................................................................2
Summary ............................................................................................................................5
1. Introduction .................................................................................................................8
2. Purpose of this Policy/Procedure .............................................................................8
3. Scope ...........................................................................................................................8
4. Definitions / Glossary .................................................................................................9
5. Ownership and Responsibilities ............................................................................. 10
5.1. Role of the Chief Executive (including the Trust Executive Board) ..................... 10
5.2. Role of the Director of Infection Prevention and Control (DIPC) .......................... 10
5.3. Role of the Integrated Infection Prevention and Control Committee (IIPCC) ...... 11
5.4. Role of the Outbreak Control Group ....................................................................... 11
5.5. Role of the Managers/Care Group Leaders/Area Directors/ Clinical Leads ......... 11
5.6. Heads of Nursing, Matrons, Ward/Team/Department Leaders ............................. 12
5.7. Role of Consultant Medical Staff ............................................................................. 12
5.8. Role of the Infection Prevention and Control Team .............................................. 12
5.9. Infection Prevention and Control Link Practitioners ............................................. 13
5.10. Role of Microbiology Department .................................................................... 13
5.11. Role of Consultant Microbiologists ................................................................. 13
5.12. Role of the RCHT Clinical Site Co-ordinators ................................................. 13
5.13. Role of the CFT On-Call Manager ..................................................................... 14
5.14. Role of Occupational Health Department ........................................................ 14
5.15. Role of the Learning and Development/Education and Training Department14
5.16. Role of Ward Staff ............................................................................................. 14
5.17. Role of Individual Staff ...................................................................................... 15
6. Standards and Practice ............................................................................................ 15
7. Dissemination and Implementation ........................................................................ 31
8. Monitoring compliance and effectiveness.............................................................. 32
9. Updating and Review ............................................................................................... 32
10. Equality and Diversity .............................................................................................. 32
10.2. Equality Impact Assessment .............................................................................. 32
Appendix 1. RCHT Governance Information ................................................................. 33
Appendix 2. RCHT Equality Impact Assessment .......................................................... 35
Appendix 3. CFT Equality Impact Assessment Form ................................................... 37
Appendix 4 - Escalation Levels ...................................................................................... 38
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Appendix 5 - Discharge During Outbreaks .................................................................... 39
Appendix 6 - Norovirus Action Card – ED Staff ............................................................ 40
Appendix 7 - Norovirus Action Card – MIU Staff ........................................................... 42
Appendix 8 - Norovirus Action Card – CATU Staff ....................................................... 44
Appendix 9 - Norovirus Action Card – Ward Staff ........................................................ 46
Appendix 10 - Norovirus Action Card – IPC Team ........................................................ 50
Appendix 11 - Norovirus Action Card – Medical Staff .................................................. 53
Appendix 12 - Norovirus Action Card – RCHT Clinical Site Co-ordinators ................ 55
Appendix 13 - Norovirus Action Card – CFT On-Call Managers .................................. 57
Appendix 14 - Norovirus Action Card – Support Staff (Porters, Supplies, etc.) ......... 59
Appendix 15 - Norovirus Action Card – Therapies Staff/Pharmacists ........................ 61
Appendix 16 - Norovirus Action Card – Domestic Services (including GSA, GFM, and
Mitie) ................................................................................................................................. 63
Appendix 17 - Norovirus Action Card - Housekeepers ................................................. 65
Appendix 18 - Membership of the Outbreak Control Team .......................................... 67
Appendix 19 - Template Agenda for OCT Meeting ........................................................ 68
Appendix 20 – Outbreak Form (Patients) ....................................................................... 69
Appendix 21 – Outbreak Form (Staff) ............................................................................. 70
Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation
The Trust has a duty under the Data Protection Act 2018 and General Data Protection
Regulations 2016/679 to ensure that there is a valid legal basis to process personal and
sensitive data. The legal basis for processing must be identified and documented before the
processing begins. In many cases we may need consent; this must be explicit, informed,
and documented. We cannot rely on opt out, it must be opt in.
Data Protection Act 2018 and General Data Protection Regulations 2016/679 is applicable
to all staff; this includes those working as contractors and providers of services.
For more information about your obligations under the Data Protection Act 2018 and
General Data Protection Regulations 2016/679 please see the Information Use Framework
Policy or contact the Information Governance Team
Cornwall NHS Foundation Trust cpn-tr.infogov@nhs.net
Royal Cornwall Hospital Trust rch-tr.infogov@nhs.net
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1. Introduction
1.1. Norovirus is a major cause of acute gastroenteritis and diarrhoea in children,
young people and adults. The cause of illness, Norovirus (previously known
as Norwalk-like or Small Round Structured Virus) was described in 1968 in
samples from an elementary school in Norwalk, Ohio (HPA 2007). The
disease is often termed Winter Vomiting Disease because of the increased
prevalence in the winter months; however it can be detected throughout the
year.
1.2. Norovirus is estimated to cost the NHS in excess of £100 million per annum
(2002-2003 figures) in years of high incidence. Approximately 3000 people a
year are admitted to hospital with norovirus in England (3) and the incidence
in the community is thought to be about 16.5% of the 17 million cases of
Infectious Intestinal Disease in England per year and there is evidence that
this burden has increased over the past decade (Gut, 2011). Hospital
outbreaks often cause major disruption in hospital activity resulting in ward
closures, cancelled admissions and delayed discharges which can
significantly reduce clinical activity for the duration of the outbreak. Failure to
observe and comply with Infection Prevention and Control guidelines/policy
can lead to further spread of infection and a delay in the hospital returning to
normal activity.
1.3. Outbreaks can affect both patients and staff, sometimes with attack rates in
excess of 50%. For this reason, staff shortages can be severe, particularly if
several wards are involved at the same time. It is therefore essential that
cases are detected early and isolated appropriately to prevent spread and
major outbreaks.
1.4. This policy should be read in conjunction with the Trusts Major Outbreak
Policy.
1.5. This version supersedes any previous versions of this document.
2. Purpose of this Policy/Procedure
2.1. This policy has been developed to provide clear infection prevention and control
guidance for all healthcare staff at the Royal Cornwall Hospitals NHS Trust and
Cornwall Partnership NHS Foundation Trust on the recognition, management
and treatment of a confirmed/suspected case or outbreak of norovirus in line with
the requirements of the Health and Social Care Act (DHSC 2015).
2.2. The policy is designed to protect patients, staff and the general public by
preventing cross-infection and contamination of the environment, and identifying
clear routes of escalation of the outbreak situation to reduce the number of
unnecessary ward closures.
3. Scope
This policy applies to all staff working for or on behalf of the Royal Cornwall
Hospitals NHS Trust and Cornwall Partnership NHS Foundation Trust, including
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volunteer, temporary, locum, bank, agency and contracted staff in their work caring
for patients.
4. Definitions / Glossary
Bristol Stool Chart
CHA 2853
Chart used to monitor patient/clients bowel movements
Case
• A suspected case of norovirus:
a) Vomiting – two or more episodes of vomiting of suspected infectious cause*
occurring in a 24-hours period
b) Diarrhoea – two or more loose stools in a 24-hour period*
c) Diarrhoea and vomiting – one or more episodes of both symptoms occurring
within a 24-hour period*
*not associated with prescribed drugs or treatments and not associated with
reaction to anaesthetic or an underlying medical condition or existing illness
(PHE 2019).
• A confirmed case of norovirus: a, b or c above with microbiological confirmation
(PHE 2019)
Contact
A person who is likely to have been exposed to a case of an infectious illness (PHE
2020)
Diarrhoea Risk Assessment (DRA)
CHA 2993
Form to be completed when a patient has type 5/6/7 stools on the Bristol Stool Chart.
Infection Prevention and Control
Referred to as IPAC by RCHT and IPC by CFT
Norovirus
A highly contagious small round structured virus capable of causing symptoms of
diarrhoea and/or vomiting (PHE, 2019)
Norovirus Pack.
A selection of materials for use by the ward in preparation for the norovirus season.
Distributed as required by the IPC team.
Outbreak
An incident in which two or more people experiencing a similar illness are linked in
time/place; or a greater than expected rate of infection compared with the usual
background rate for the place and time where the outbreak has occurred (PHE 2014).
• Suspected Outbreak
Two or more cases, as defined above, occurring in a functional care unit (e.g. ward
or bay) within a hospital without laboratory confirmation (PHE 2019)
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• Confirmed Outbreak
Two or more cases, as defined above, occurring in a functional care unit (e.g. a ward
or bay) within a hospital with laboratory confirmation (PHE 2019)
• In the absence of laboratory confirmation, the following criteria can be used as a
rough indicator of a norovirus outbreak:
▪ Average duration of illness of 12 to 60 hours
▪ Average incubation period of 24 to 48 hours
▪ More than 50% of people with vomiting and
▪ No bacterial agent found (PHE 2019)
Pathogen - A microorganism that causes disease (Loveday et al 2014)
PCR test – Polymerase Chain Reaction (PHE 2020)
5. Ownership and Responsibilities
5.1. Role of the Chief Executive (including the Trust Executive
Board)
The Chief Executive (and the Trust Executive Board) is responsible for:
• Ensuring that infection prevention and control is a core part of clinical
governance and patient safety programmes.
• Promoting compliance with infection prevention and control policies in order
to ensure low levels of health care associated infections.
• Awareness of legal responsibilities to identify, assess and control risk of
infection
• Appointing a Director of infection Prevention and Control.
5.2. Role of the Director of Infection Prevention and Control (DIPC)
The DHSC (2015) defines the role of Director of Infection Prevention and Control
specifying that they:
• Provide oversight and assurance on infection prevention (including
cleanliness) to the Trust board or equivalent. They should report directly to
the Board but are not required to be a Board member.
• Be responsible for leading the organisation’s infection prevention team.
• Oversee local prevention of infection policies and their implementation.
• Be a full member of the Infection Prevention and Control Team (IPC) and
antimicrobial stewardship committee and regularly attend its infection
prevention meetings.
• Have the authority to challenge inappropriate practice and inappropriate
antimicrobial prescribing decisions.
• Have the authority to set and challenge standards of cleanliness.
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• Assess the impact of all existing and new policies on infections and make
recommendations for a change.
• Be an integral member of the organisation’s clinical governance and patient
safety teams and structures, water safety group; and
• Produce an annual report and release it publicly as outlined in Winning ways:
working together to reduce healthcare associated infection in England
(2003).
• Additionally, the DIPC is responsible for:
• Arranging for the Outbreak meetings to take place.
• Being an active member of the Outbreak Control Group and chair the
outbreak meetings.
• Including information of the ward closures and bed days lost in reports for
discussion at the Integrated Infection Prevention and Control Committee
meeting.
• Seeking advice from Public Health England.
5.3. Role of the Integrated Infection Prevention and Control
Committee (IIPCC)
The Integrated Infection Prevention and Control Committee is responsible for:
• Approving this policy
• Monitoring the implementation of this policy
5.4. Role of the Outbreak Control Group
The Outbreak Control Group is responsible for:
• Monitoring compliance with this policy via the outbreak meetings
• Monitoring and advising on the prevention and spread of the virus.
• Reviewing the decision of open/closed status of wards
• Reviewing the frequency of cleaning of affected areas
5.5. Role of the Managers/Care Group Leaders/Area Directors/
Clinical Leads
The Care Group Leaders/Area Directors/Clinical Leads are responsible for:
• Ensuring dissemination and implementation of this policy
• Ensuring action is taken when staff fail to comply with the policy
• Ensuring that resources are available for health care workers, patients and
visitors to undertake effective standard and isolation precautions/comply with
this policy
• Ensuring this policy is accessible to all staff
• Being active members of the Outbreak Control Group (when an outbreak
affects their area)
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• Promoting good practice
• Challenging poor compliance
5.6. Heads of Nursing, Matrons, Ward/Team/Department Leaders
The Heads of Nursing, Matrons, Ward/Team/Department Leaders, are responsible
for:
• Ensuring all staff are aware of and adhere to this policy
• Ensuring implementation of this policy within their area
• Ensuring that the norovirus toolbox briefing is cascaded to all staff during the
first 2 weeks of November.
• Ensuring that any member of staff who is absent during this period receive
an update of the norovirus toolbox briefing as soon as possible on their return.
• Ensuring an attendance record for the norovirus toolbox talk is submitted to
the Education and Training/Learning and Development Department
• Ensuring that the Occupational Health Department are informed of any staff
with symptoms of diarrhoea and/or vomiting during outbreaks of norovirus.
• Being active members of the Outbreak Control Group (when an outbreak
affects their area)
• Promoting good practice
• Challenging poor compliance
5.7. Role of Consultant Medical Staff
Consultant Medical Staff are responsible for:
• Ensuring their staff adhere to this policy
• Reviewing patients with suspected norovirus
• Undertaking actions as per the appropriate action card (Appendix 12).
• Promoting good practice
• Challenging poor compliance
5.8. Role of the Infection Prevention and Control Team
The Infection Prevention and Control Team are responsible for:
• Reviewing and updating this policy
• Ensuring this policy remains consistent with the evidence-base for safe
practice
• Overseeing and supporting staff with the implementation of this policy
• Providing expert advice on the management of patients with
suspected/confirmed norovirus in accordance with this policy
• Following actions on the relevant action card at appropriate escalation levels
(Appendix 11)
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• The co-ordination of stool specimen collection and testing
• Dealing with the infection control aspects of specimen results
• Informing the DIPC and other relevant parties of bay/ward closures
• Assisting with risk assessment where complex decisions are required
• Promoting good practice
• Challenging poor compliance
5.9. Infection Prevention and Control Link Practitioners
The Infection Prevention and Control Link Practitioners are responsible for:
• Adhering to this policy
• Support staff with the implementation of the policy
• Reporting breaches of this policy to the person in charge or line manager
• Promoting good practice
• Challenging poor compliance
5.10. Role of Microbiology Department
The microbiology laboratory is responsible for:
• Providing a same day testing service for faecal specimens received by
agreed times (See section 6) for local laboratories when sanctioned by the
IP&C team/microbiologists/site-coordinators/on call managers.
• Informing the Consultant Microbiologists/IP&C team of laboratory specimen
results
5.11. Role of Consultant Microbiologists
The Consultant Microbiologists are responsible for:
• Contributing to the development/review of this policy
• Informing the relevant ward and/or the IP&C team of laboratory specimen
results
• Assisting with the decision to de-escalate isolation of patients
5.12. Role of the RCHT Clinical Site Co-ordinators
The Clinical Site Co-ordinators are responsible for:
• Ensuring suspected cases of norovirus are isolated in accordance with this
policy
• Ensuring there is no movement of patients unless there is an urgent clinical
need. The IPC team need to be informed of the transfers.
• Following actions on the relevant action card at appropriate escalation levels
(Appendix 13)
• Co-ordinating terminal cleaning plan when areas are due to re-open.
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5.13. Role of the CFT On-Call Manager
The CFT On-Call Manager is responsible for:
• Following actions on the relevant action card at appropriate escalation levels
(Appendix 14)
• Ensuring suspected cases of norovirus are isolated in accordance with this
policy.
• Ensuring there is no movement of patients unless there is an urgent clinical
need.
• Following action on the relevant action card at appropriate escalation levels
(Appendix 5)
5.14. Role of Occupational Health Department
The Occupational Health Department are responsible for:
• Contributing to the development/review of this policy
• Collating information on staff with symptoms of diarrhoea and/or vomiting
• Being active members of the Outbreak Control Group
• Informing the IP&C team of areas with increased incidence of symptoms.
5.15. Role of the Learning and Development/Education and Training
Department
The Learning and Development/Education and Training Department are
responsible for:
• Ensuring the Training Needs Analysis is updated for all staff
• Maintaining staff records to monitor attendance at norovirus toolkit annual
updates
5.16. Role of Ward Staff
Ward staff are responsible for:
• Following actions on the relevant action card (see Appendix 10) at
appropriate escalation levels (Appendix 5)
• Ensuring vigilance for all cases of diarrhoea and/or vomiting and that stool
charts are maintained accurately and consistently
• Report any cases of suspected infectious diarrhoea to the IP&C team or Site
Co-ordinators/On Call Managers out of hours.
• Ensuring stool specimens are collected and submitted promptly and that the
completion of the relevant documentation has been carried out i.e. stool
charts.
• Reporting and recording details of patients with suspected norovirus and
providing an up to date list on a daily basis to the IP&C team.
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5.17. Role of Individual Staff
All staff working for or on behalf of Royal Cornwall Hospitals NHS Trust and
Cornwall Partnership NHS Foundation Trust including volunteer, temporary,
locum, bank, agency and contracted staff are responsible for:
• Adhering to this policy
• Following actions on the relevant action card at appropriate escalation levels
(Appendix 5)
• Carrying out effective Infection Prevention and Control procedures
• Acting in a way which minimises risk to the patient
• Attending a norovirus toolbox briefing during the first two weeks of November
if they work in a clinical area. Any member of staff who is absent during this
period should receive an update as soon as possible on their return.
• Report breaches of this policy to the person in charge and line manager
• Contractors working on site will take advice on continuation of work from the
IPC Team and/or project lead
6. Standards and Practice
6.1. Signs and Symptoms of Norovirus
6.1.1. The average incubation period for norovirus associated gastroenteritis is
12-62 hours (PHE 2019).
6.1.2. The illness is characterized by a sudden acute onset of:
• Vomiting (this is the predominant symptom, often projectile, and is
seen in 50% of cases, however, clusters can occur where vomiting is
infrequent or absent altogether).
• Watery diarrhoea and abdominal cramps
• Nausea
• In addition headache, myalgia, fever and malaise are common.
• Some or all of the above symptoms may be present.
6.2. Transmission
6.2.1. Norovirus is highly contagious. It is estimated that around 30,000,000 (30
million) viral particles are released during one vomiting incident.
However, it only takes around 100 of these particles to cause illness.
6.2.2. Norovirus is transmitted primarily through the faecal–oral route either by
person to person spread or via contaminated food or water. In addition
norovirus can be spread via aerosol dissemination of infected particles
following vomiting. Transmission can also occur through hand transfer of
the virus to the oral mucosa following contact with environmental
surfaces, fomites and equipment which have been contaminated with
either faeces or vomit.
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6.2.3. Norovirus can survive for up to 12 days on some surfaces.
6.3. Diagnosis
6.3.1. Norovirus may be suspected clinically in individuals with sudden onset of
vomiting followed by diarrhoea. Some people may present with similar
symptoms but may be identified as having different aetiologies (causes
or diagnosis). A diarrhoea risk assessment must be completed in all
cases of patients/clients/service-users with diarrhoea. A medical review
is essential when determining the cause of vomiting/diarrhoea.
6.3.2. Norovirus testing will only be performed after discussion with the
Infection Prevention and Control team or Microbiologists.
6.3.3. Confirmation of norovirus infection depends on a PCR test performed on
faecal/stool samples as soon as an outbreak is suspected (see section 4.
Definitions). Vomit samples will not be tested for norovirus so are not to
be sent to the laboratory.
6.3.4. Stool samples sent throughout the week and over the weekend should
be sent to the local Microbiology laboratory using local protocols so they
are not delayed.
6.3.5. For RCHT (Royal Cornwall Hospitals NHS Trust) laboratory facing sites,
testing is available daily with a result available the same day for samples
arriving at the laboratory before 10.00hrs.
6.3.6. For UHP (University Hospitals Plymouth) laboratory facing sites, same
day results will be available for samples received by 11.00hrs.
6.3.7. For North Devon laboratory facing sites, same day results will be
available for samples received by 18.00hrs.
6.3.8. During an outbreak several people are commonly affected over a short
space of time and cases with typical features may be ascribed to
norovirus infection without further testing, this will be a decision for the
group at the outbreak meeting.
6.3.9. Once norovirus is identified on a ward, further testing will only be
performed in order to determine whether norovirus shedding is occurring
in cases of persistent diarrhoea or whether the virus has spread
throughout the ward. Norovirus testing may be performed in order to
identify atypical or outlying cases.
6.3.10. When an outbreak is suspected, it is imperative to institute infection
control measures immediately without waiting for
virological/laboratory confirmation from stool testing.
6.3.11. There is no requirement for laboratory testing of faeces for norovirus in
defining viral clearance in patients who have formed stools (Type 1-4 on
the Bristol Stool chart).
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6.3.12. SIGHT mnemonic
Healthcare Professionals should apply the following mnemonic protocol
(SIGHT) when managing suspected potential infectious diarrhoea;
Table 1: SIGHT mnemonic
S Suspect that a case may be infective where there is no clear alternative for
cause for diarrhoea
I Isolate the patient and consult with the IP&C Team while determining the
cause of diarrhoea
G Gloves and aprons must be used for all contacts with the patient and their
environment
H Hand washing with soap and water should be carried out before and after
each contact with the patient and the patients environment
T Test the stool by sending a specimen immediately
(Source: PHE 2013)
6.4. Treatment
6.4.1. There is no effective treatment for norovirus. It is a self-limiting illness
which usually ceases within a few days.
6.4.2. Dehydration is the most common complication of norovirus. It is
important to ensure prompt fluid replacement to prevent dehydration and
its complications.
6.4.3. Anti-emetics or anti-motility agents must not be prescribed or
administered.
6.4.4. Laxative usage should be reviewed by the medical team.
6.5. Standard Precautions
6.5.1. Hand Hygiene
6.5.1.1. The hands of healthcare staff can provide the vehicle for the
transmission of norovirus.
6.5.1.2. It is essential that all staff wash their hands when required
using the correct hand washing technique to help reduce the
risk of transmission.
6.5.1.3. Alcohol gel is not effective against these viruses and
therefore hands must be washed with soap and water before
and after every patient contact and contact with potentially
infectious equipment, furnishings or other fomites.
6.5.1.4. Gloves do not obviate the need to wash hands.
6.5.1.5. Patients/clients/service-users must be provided with the
opportunity or be assisted to wash their hands with soap and
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water or use hand wipes after each toileting episode and
before each meal.
6.5.1.6. Handwashing facilities should be available at entrances to
closed areas. These may be mobile units if permanent
facilities are not available (Norovirus Working Party (NWP)
2012).
6.5.1.7. For further information on hand hygiene, please refer to the
Trusts Standard Precautions / Hand Hygiene Policies.
6.5.2. Personal Protective Equipment (PPE)
6.5.2.1. Aprons and gloves must be used appropriately (single use
items) by staff for each episode of
care/treatment/examination for all patients/clients/service-
users.
6.5.2.2. Aprons and gloves must be used appropriately (single use
items) by staff cleaning the environment/equipment.
6.5.2.3. NB. Long sleeved gowns must be worn by staff who are not
specifically allocated to care for affected patients but who are
called on to assist with the care of affected patients plus any
visiting personnel required to have patient contact. These
must be changed for each episode of care.
6.5.2.4. Eye and face protection must be worn if there is a risk of
droplet or aerosol splash contamination.
6.5.2.5. After use, PPE must be disposed of in accordance with the
Trust’s Waste Management Policy
6.5.2.6. For further information, please refer to the Trusts Standard
Precautions / Personal Protective Equipment policies.
6.5.3. Management of Norovirus Cases
6.5.3.1. The priority is to ensure that patient/client/service-user care is
not compromised and at the same time prevent the spread of
the virus to other susceptible individuals and prevent a major
hospital outbreak.
6.5.3.2. The management of a suspected or confirmed outbreak of
norovirus should be advised by the IPC Team and supported
by the key personnel in the Trusts responsible for patient stay
and their holistic care.
6.5.4. Isolation in single-occupancy rooms
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6.5.4.1. Symptomatic patients/clients/service-users should be nursed
in isolation where possible to minimise transmission (source
isolation).
6.5.4.2. Any patient/client/service-users admitted to Royal Cornwall
Hospital Emergency Department with symptoms suggestive
of norovirus must be triaged and fast tracked to the isolation
ward. Where the patient/client/service-user condition does
not allow admission to the isolation ward at Royal Cornwall
Hospital, they must be admitted to a single-occupancy room
to avoid admitting to AMU.
6.5.4.3. Where patients/clients/service-users are admitted to another
hospital within Cornwall and the Isles of Scilly or directly to a
ward at Royal Cornwall Hospital with symptoms suggestive of
norovirus, they must be admitted to a single-occupancy room.
6.5.4.4. Where patients/clients/service-users are admitted from Care
Homes or other organisations identified as having a
suspected/confirmed outbreak of norovirus/viral
gastroenteritis, they must be admitted to a single-occupancy
room and remain in isolation until 72 hours have elapsed
since their last symptom.
6.5.4.5. The Infection Prevention and Control Team must be informed
at the earliest opportunity of the patient/client/service-user’s
admission to any hospital throughout Cornwall and the Isles
of Scilly.
6.5.4.6. Doors to single-occupancy rooms MUST remain closed. A
risk assessment of the safety of the patient whilst isolated
must be undertaken prior to isolation/door closure including
any mitigating measures identified. This should be
documented as per the Trust’s Clinical Record Keeping
Policy.
6.5.4.7. The allocation of a single-occupancy room should be
prioritised as per the Trust’s Isolation/Patient Movement and
Placement Policy. If staff are unsure whether a
patient/client/service-user already in a single-occupancy
room can be de-isolated, the Infection Prevention and Control
Team must be contacted (out of hours, contact the
Consultant Microbiologist via switchboard or the on-call
Manager for CFT).
6.5.4.8. A poster (available in the norovirus pack) must be displayed
on the door of the affected single-occupancy room.
6.5.4.9. Affected patients/clients/service users must have;
• Dedicated staff
• dedicated commodes/toilet facilities.
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• dedicated equipment e.g. monitoring equipment.
6.5.4.10. It is essential that if an area is affected by norovirus,
discharge planning is continued.
6.5.5. Bay closure
6.5.5.1. Bay closure will be made by the IPC team in hours and Site
Coordinator out of hours following assessment of the area
where the diarrhoea / vomiting symptoms have occurred.
6.5.5.2. If a patient/client/service-user develops symptoms of
suspected norovirus and they are in a bay with others, the
patient/client/service-user should be isolated in a single-
occupancy room on that ward and the whole bay must be
closed immediately in an attempt to contain the spread of
infection from both affected and exposed patients. If the
affected patient/client/service-user is within a single-
occupancy room that is located within a bay, the whole
bay must be closed. This decision should be made:
• Within hours by the Nurse-in-Charge/Ward-
Leader/Matron and Infection Prevention and Control
Team
• Out of hours by the Nurse-in-Charge/Ward-
Leader/Matron and RCHT Site Coordinator/CFT On-Call
Manager
6.5.5.3. An urgent senior clinical assessment must be completed to
determine if the bay should remain closed. This should be
carried out by the following:
• Within hours - the Infection Prevention and Control
team, Matron/Ward Leader and Consultant/Medical
team
• Out of hours - the RCHT Site Coordinator/CFT On-Call
Manager, On-Call Microbiologist and On-Call
registrar/Consultant/out of hours doctor.
6.5.5.4. Where there are multiple cases in excess of available single-
occupancy room provision, patients/clients/service-users
should be cohort-nursed in bays. Avoid cohort nursing
individuals with diarrhoea of different aetiologies (causes or
diagnosis). Be aware that patients may present with similar
symptoms but may be identified as having different
aetiologies.
6.5.5.5. Patients/clients/service-users within a ward must not be
moved between bays to cohort nurse unless advised by
the IPC team/Outbreak Control Group.
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6.5.5.6. The open/closed status of any affected bay must be reviewed
and decided by the Outbreak Control Group (see
Management of Outbreaks Policy).
6.5.5.7. Doors to bays MUST remain closed. A risk assessment of
the safety of the patient/client/service-user(s) whilst isolated
must be undertaken prior to isolation/door closure including
any mitigating measures identified. This should be
documented as per the Trust’s Clinical Record Keeping
Policy.
6.5.5.8. A poster (available in the norovirus pack) must be displayed
on the affected bay(s) door(s) advising that there is an
outbreak of diarrhoea and/or vomiting.
6.5.5.9. Affected cohorted patients/clients/service users must have;
• Dedicated staff
• Dedicated commodes/toilet facilities.
• Dedicated equipment e.g. monitoring equipment.
6.5.5.10. It is essential that if an area is affected by norovirus,
discharge planning is continued.
6.5.6. Ward Closure
6.5.6.1. Ward closure will be made following assessment of the area
where the diarrhoea / vomiting symptoms have occurred.
6.5.6.2. Within RCHT, when 2 or more bays are affected actions are
required to ensure that the unaffected bays within the ward
can remain open, including:
• Revised staffing to enable separate staffing of affected
and unaffected areas
• Confirmation that the ward design permits effective
isolation of affected from unaffected areas
• Assessment of availability of designated toilet facilities.
6.5.6.3. Full ward closure should be undertaken if it is not possible to
implement these identified additional infection prevention
actions, and the ward must remain closed until these required
measures have been achieved.
6.5.6.4. Within CFT, due to the varying layouts, ward closure will be
assessed on an individual basis. As a general rule, if
norovirus is confirmed on a ward and 50% of the ward is
affected by either confirmed, suspected or exposed
patients/clients/service-users the ward will be closed,
however this is ultimately the decision of the DIPC and
Outbreak Control Group.
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6.5.6.5. Where an outbreak of suspected/confirmed norovirus is
identified it is vital that the Infection Prevention and Control
Team (within hours)/On Call Managers and Site co-ordinators
(out of hours) are informed.
6.5.6.6. No patients can be admitted onto a ward once it has
been closed for infection control reasons.
6.5.6.7. Mental Health context: There may be occasions when a
decision is needed to admit a patient into a closed ward as
their mental health condition outweighs the risk of infection
e.g. within adult mental health. A decision to admit into a
closed ward can only be taken following discussion with the
DIPC or Deputy DIPC and careful risk assessment on the
understanding that there are no other Mental Health inpatient
beds available in other inpatient facilities
6.5.6.8. The ongoing open/closed status of any affected ward must be
reviewed and decided by the Outbreak Control Group.
6.5.6.9. A poster (available in the norovirus pack) must be displayed
at the entrance of the ward advising that there is an outbreak
of diarrhoea and vomiting. Only essential visits can be
made to closed wards to limit potential spread.
6.5.6.10. Affected cohorted patients/clients/service users must have;
• Dedicated staff
• Dedicated commodes/toilet facilities.
• Dedicated equipment e.g. monitoring equipment.
6.5.6.11. Doors to single-occupancy rooms and bays MUST remain
closed. A risk assessment of the safety of the individual
patient/client/service-user(s) whilst isolated must be
undertaken prior to isolation/door closure including any
mitigating measures identified. This should be documented
as per the Trusts Clinical Record Keeping Policy.
6.5.6.12. It is essential that if an area is affected by norovirus,
discharge planning is continued.
6.6. Admission and/or Transfer from a Closed Bay or Ward
6.6.1. Admission
6.6.1.1. There must be no admissions to the closed bay/ward until
advised by the IPC team/Outbreak Control Group.
6.6.1.2. The movement of affected patients/clients/service-users from
one ward to another for cohort management is NOT
recommended.
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6.6.2. Transfer to other Departments from a Closed Bay or Ward
6.6.2.1. There must be no transfer of patients/clients/service-users to
other departments from norovirus closed bay or ward unless
there is an urgent clinical need in which case the receiving
department and transport services must be informed in
advance of the transfer. Transfers from a closed area must
be discussed with the IPC team or Outbreak Control Group
(within hours)/ On-call clinical manager or Site co-ordinator
(out of hours). In this situation, the following must occur:
• Arrangements must be made to minimise contact with
other patients/clients/service-users.
• The patient/client/service-user must be seen
immediately on arrival to the department and preferably
at the end of a list.
• Minimal numbers of staff to attend the
patient/client/service-user, whilst maintaining patient
safety.
• Long sleeved gowns and gloves must be worn by
attending staff.
• All equipment that the patient/client/service-user has
come into contact with must be cleaned with Clinell
sporicidal wipes or a chlorine based disinfectant e.g.
Actichlor Plus (1,000 ppm available chlorine combined
with detergent).
• The patient/client/service-user must return directly to the
ward and must not wait in a waiting area with others.
6.6.3. Transfer to other Hospitals from a Closed Bay or Ward
There must be no transfer of patients/clients/service-users to other
hospitals from a bay/ward closed due to norovirus unless there is an
urgent clinical need in which case the receiving department must be
informed in advance of the transfer. Transfers from a closed area must
be discussed with the IPC team or Outbreak Control Group (within
hours)/ On-call clinical manager or Site co-ordinator (out of hours).
6.6.4. Patients from a Closed Bay/Ward who require Surgery
In the event of the patient/client/service-user requiring surgery, the
following must occur:
• Theatre staff must be informed that the patient/client/service-user
is from a norovirus affected ward/experiencing norovirus
symptoms.
• The consultant in charge of the patient/client/service-user’s care is
responsible for the decision to continue with surgery. The decision
must be documented in the medical records and the
patient/client/service-user must be informed as per Trust Policies.
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• The patient/client/service-user should be placed last on the theatre
list, go directly to the anaesthetic room and must be recovered in
the theatre. The individual must not be recovered in the
Recovery area with other patients/clients/service-users.
• Minimal numbers of staff to be in the theatre whilst ensuring
patient/client/service-user safety.
• The theatre, all equipment and anaesthetic room must be cleaned
thoroughly using a chlorine based disinfectant after the
patient/client/service-user has left theatre.
• All equipment that the patient/client/service-user has come into
contact with must be cleaned with Clinell sporicidal wipes or a
chlorine based disinfectant e.g. Actichlor Plus (1,000 ppm
available chlorine combined with detergent).
• If the patient/client/service-user is due to have elective surgery
and has symptoms of norovirus, it is advised not to continue with
surgery until symptoms have resolved though this must be the
decision of the consultant in charge of the individual’s care. The
decision must be documented in the medical records and the
patient/client/service-user informed.
6.6.5. Discharge from a Closed Bay or Ward
6.6.5.1. A patient/client/service-user considered fit for discharge from any
area closed due to suspected or confirmed norovirus should be
discharged as per the Cornwall and Isles of Scilly Whole System
Norovirus Plan (Appendix 6)
6.6.5.2. See Discharge During Outbreaks (Appendix 6)
6.6.5.3. Patients can be discharged from norovirus affected areas to their
own homes if deemed medically fit for discharge as per the
Cornwall and Isles of Scilly Whole System Norovirus Plan
(Appendix 5, and located in the norovirus pack.
6.7. Linen
6.7.1. All linen from a norovirus affected area must be managed as infected
linen as per the Trust’s Linen/Laundry Policy.
6.7.2. If clothing from symptomatic patients is returned to relatives or carers for
laundering, they should be given verbal and/or written instruction on how
to safely launder the items in the home setting.
6.8. Waste
All waste from an affected area must be managed as infectious waste as per the
Trusts Waste Management Policy.
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6.9. Management of the Affected Patient Environment
6.9.1. Domestic Services must be informed by the ward staff of the situation
within a single-occupancy room, bay or ward re the requirement for
enhanced cleaning. Frequently touched surfaces such as bed tables, bed
rails, the arms of chairs, taps, call bells, door handles and push plates must
be cleaned more frequently during an outbreak (frequency to be
determined by the Outbreak Control Group).
6.9.2. Effective cleaning and removal of organic soiling prior to disinfection
is essential to maximise the effectiveness of surface disinfectants.
6.9.3. Use single use items of equipment wherever possible
6.9.4. Symptomatic patients/clients/service-users must have dedicated
commode/toilet facilities and dedicated equipment e.g. monitoring
equipment.
6.9.5. Shared equipment must be cleaned and disinfected with Clinell
sporicidal wipes or an Actichlor Plus solution (1,000 ppm available
chlorine combined with detergent) between each patient use in line
with the manufacturer’s recommendations.
6.9.6. If equipment requires repair during an outbreak it must be reported as
per local protocols. Ensure the repair team are informed that the
bay/ward is closed. Equipment awaiting repair must be cleaned and
disinfected and labelled accordingly in line with the manufacturer’s
recommendations.
6.9.7. Water jugs must be kept covered to prevent the water from becoming
contaminated, washed thoroughly each day in a dishwasher, and the
water changed frequently.
6.9.8. Bowls of fruit and open packets of food, i.e. biscuits, must be removed
as they may become contaminated as a result of aerosol
contamination.
6.9.9. Housekeeping trolleys (e.g. tea trolleys) must not be taken into
affected/closed single-occupancy rooms or bays.
6.9.10. Medication trolleys must not be taken into affected/closed single-
occupancy rooms or bays.
6.9.11. For further information on cleaning and disinfecting equipment, please
refer to the Trust’s Cleaning/Decontamination Policy.
6.9.12. Whilst a bay or ward is closed during an outbreak, the area must be
cleaned with both detergent and chlorine e.g. Actichlor Plus.
6.9.13. Increase the frequency of cleaning and disinfection of patient care
areas and toilet facilities, including frequently touched surfaces such
as light switches, taps, door handles, flush handles and toilet seats
Joint Outbreaks of Suspected or Confirmed Norovirus Policy V1.1
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