SOP Objective

To ensure that Healthcare Workers (HCWs) are aware of the actions and precautions necessary to minimise the risk of outbreaks and the importance of diagnosing patients’ clinical conditions promptly. To provide a framework for the identification and control of outbreaks in healthcare premises.

This SOP relates solely to OUTBREAKS IN HOSPITALS.

This policy applies to all staff employed by NHS Greater Glasgow & Clyde and locum staff on fixed term contracts and volunteer staff.

KEY CHANGES FROM THE PREVIOUS VERSION OF THIS POLICY

Updated organisational roles and responsibilities as per the Acute Servce Review

Reccommedation 16 Vale of Leven Hospital Enquiry Report 2014

HCW is required to complete Outbreak Module on Learn Pro every three years.

Document Control Summary

Approved by and date	Board Infection Control Committee 30th November 2015
Date of Publication	30th November 2015
Developed by	Infection Prevention and Control Policy Sub-Group
Related Documents	NHSGGC Hand Hygiene Policy NHSGGC SOP Staff Screening NHSGGC Transmission Based Precautions Policy NHSGGC SOP Cleaning of Near Patient Equipment NHSGGC SOP Twice Daily Clean of Isolation Rooms NHSGGC SOP Terminal Clean of Isolation Rooms NHSGGC SOP Terminal Clean of Ward
Distribution/ Availability	NHSGGC Infection Prevention and Control online Policy Manual www.nhsggc.org.uk/your-health/public-health/infection-prevention-and-control/
Implications of Race Equality and other diversity duties for this document	This policy must be implemented fairly and without prejudice whether on the grounds of race, gender, sexual orientation or religion.
Lead Manager	Board Infection Control Manager
Responsible Director	Board Medical Director

CONTENTS

1.	Responsibilities	4

2.	Reporting of incidents with the potential to cause outbreaks	5

3.	Outbreak Definitions	5

4.	Information for the IPCT	5

5.	Actions of the IPCT	6

5.1 Case finding	6

5.2 Institute control measures - IPCT	6

5.3 Seek additional cases and collect data and specimens	7

5.4 Formulate tentative hypothesis	8

5.5 Ward closures	8

6.	Communicate and facilitate hospital management of the outbreak	8

6.1 The Sector IPCT will inform (Acute inpatient sites) :	8

Consultant in Charge (acute only)/ Receiving Consultant and Lead Clinician	9

Out of Hours – The Consultant Microbiologist on-call will close the ward and inform the IPCNs but it will be the responsibility of the Nurse in Charge to inform the Site Co-ordinator and on-call Manager	10

6.1(b) The IPCT will inform (Partnerships inpatient sites):	10

Out of Hours – The Consultant Microbiologist on-call will close the ward and inform the IPCNs but it will be the responsibility of the Nurse in Charge to inform the Site Co-ordinator and on-call Manager	11

6.2 Board Infection Control Manager / Co-ordinating Infection Control Doctor or Associate Nurse Director Infection Prevention and Control will inform:	11

6.3 NHSGGC Communications Officer will:	11

6.4 OCT	11

6.5 OCT Meetings	12

6.6 Chairing the OCT	12

6.7 Reporting the Outbreak	12

6.8 Formal report of the OCT	13

7.	Suggested template of OCT Report:	13

8.	Instructions for a closed ward: Infection Prevention Control Advice	14

9.	Suggested Agenda for First OCT Meeting	15

10.	Staff Screening	16

11.	The Hospital Infection Incident Assessment (HIIA)Tool	17

12.	Evidence Base and Regulations	18

Appendix 1 – Acute Division Ward Closure	19

Appendix 2 – Wards with all single room accommodation ............................................. 20

Responsibilities

Healthcare Workers (HCWs) must:

Follow this policy.

Follow the advice of the Infection Prevention Control Team (IPCT) / Outbreak Control Team (OCT).

Report to the IPCT at any time when they suspect there may be an outbreak (see definitions).

Communicate with patients and relatives, and document in clinical notes that this has taken place.

Complete Outbreak Module on Learnpro at least every three years.

Senior Charge Nurses / Managers must:

Report suspected outbreaks of infection (Clostridium difficile) to the Infection Prevention and Control Team – recommendation 16, Vale of Leven Hospital Enquiry Report.

Fully consider the advice of the IPCT or OCT.

Support the IPCT / OCT in bringing the outbreak to a halt.

IPCT / OCT must:

Investigate all reports of possible outbreaks.

Review the need to close or open wards to control an outbreak.

Take all necessary actions to identify the cause of and bring the outbreak to a close.

Make recommendations to prevent recurrence.

Communicate both within and outwith NHSGGC, as specified within the NHSGGC Outbreak Policy (Section 11 page 13 HIIAT).

Communicate with Occupational Health regarding the treatment and potential staff screening during the outbreak.

Keep this policy up-to-date through the NHSGGC Board Infection Control Committee (BICC).

Public Health Protection Unit (PHPU) NHSGGC must:

Consider the need to chair the OCT at the request of the Service.

Support and advise the OCT as required.

Occupational Health Service (OHS) must:

Support the implementation of the relevant NHSGGC Policy.

Support and advise staff as required.

Support and advise the OCT.

Co-ordinate and collate staff screening results and ensure treatment and fitness for work advice is provided.

Reporting of incidents with the potential to cause outbreaks

HCWs who suspect that an outbreak may be occurring must contact a member of the IPCT without delay.

Outbreak Definitions

Two or more linked cases with the same infectious agent associated with the same clinical setting, or

A higher than expected number of cases in a given clinical area over a specified time period, or

A single case of a serious illness with major public health implications where action is necessary to investigate and prevent ongoing exposure to a hazardous agent.

Once an outbreak is reported to a member of the IPCT, the IPCT will take the action detailed in Section 5.

Information for the IPCT

When reporting any of the above to a member of the IPCT, the following information should be available: patients name, CHI number, admission date and admission history, relevant information on drug treatment, symptom history (including date and time of onset) and position / placement in the ward.

Actions of the IPCT

Confirm that an outbreak exists by carrying out the following:

5.1 Case finding

Form a case definition and use it to estimate the magnitude of the problem. The case definition may change as new information is gathered, e.g. early case definition.

Identify all the patients with either, the same and / or related symptoms, diagnosis or micro-organism, within a particular timeframe.

Compare current incidence with usual or baseline incidence.

Form an opinion on the severity of the outbreak as per Section 11 HIIAT.

If the most likely explanation is that there is an outbreak, implement the Communication Chain (Section 6.1) and decide on the need for an OCT based on the agreed outbreak severity (Section 11).

Obtain laboratory specimen results to identify specific agent responsible.

5.2 Institute control measures - IPCT

Based on the magnitude and nature of the problem the IPCT will institute control measures. The control measures may include, but are not limited to:

Close ward to new admissions, transfers in and out. Patients may be discharged to their own home if asymptomatic or deemed medically fit for discharge. Clinical staff will discuss any possible risks with relatives and advise and document accordingly.

Advise on isolation / cohort of cases in a designated area and stop admissions and transfers of symptomatic patients. (Exceptions would be outbreaks of Norovirus when cohorting has a limited effect.) Doors to isolation rooms/cohort areas should be closed at all times.

Advise on restricting HCWs movements between affected ward and other areas, as far as possible.

Advise HCWs on the possible modes of spread, appropriate hand hygiene and Personal Protective Equipment (PPE).

Advise increasing environmental cleaning to twice daily with chlorine based detergent, following SOP Twice Daily Clean of Isolation Rooms.

Issue care plans and advice leaflets if available and advise staff to document their issue to patients / relative / carers.

IPCN will visit and discuss with patients or their relatives / carers the specific alert organism or communicable disease identified (excludes Norovirus).

Confirm what specimens have been taken and request new specimens as necessary. HCWs must ensure specimens are clearly labelled with patient information and relevant clinical history.

Request other items that may be required for the investigation of source, e.g. food samples.

Advise HCWs to keep the Infection Prevention Control Nurse (IPCN) up-to-date of any change in the number of cases or deterioration in individual cases (including staff).

Ensure HCWs are aware of control measures (leave documentation, i.e. complete and leave Section 8 Instructions for a closed ward: IPC advice of this policy).

Provide education sessions for staff on the modes of transmission, pathogenicity and epidemiology of the organism identified (excludes Norovirus) if required.

Advise staff on communication with patients and relatives.

Consider restricting visitors to affected wards.

Consider immunisation of susceptible patients as appropriate.

5.3 Seek additional cases and collect data and specimens

The IPCT should encourage immediate reporting of new cases, either clinically suspected or laboratory confirmed.

The IPCT will consider the need to request screening of patients and /or HCWs. (The decision to screen HCWs will be made by the OCT). See Section 10 Staff Screening.

The IPCT will consider contacting PHPU to determine if they are aware of any other cases in the community.

5.4 Formulate tentative hypothesis

On the basis of analysis of cases (and other information if necessary) develop a hypothesis on the likely reservoir, sources and modes of transmission. There may be several reasonable hypotheses.

If possible, test the hypothesis by sending appropriate samples or stopping interventions that are thought to have caused the outbreak.

If deemed necessary, the OCT will undertake a case control study or a cohort study.

5.5 Ward closures

Wards may be closed by the IPCT when there is suspicion of an outbreak or where there is a definite outbreak. The IPCT will inform the organisation as per Section 6.1 in the NHSGGC Outbreak Policy.

The decision to admit a patient to a closed ward against the advice of the IPCT should be approved by the relevant Director. The reason for this should be fully documented via the incident recording system, i.e. Datix. Out-of-hours the on-call duty manager should discuss any situation where there may be a decision to admit to a closed ward, with the on-call Director. It is accepted that any decision around this is based on the balance of risk. The Significant Clinical Incident Policy provides a framework for the investigation of significant clinical incidents and the supporting toolkit may be utilised to support investigation of specific cases identified through the outbreak review process. OCT reports will be logged into Datix after the chair of the OCT has approved them (excluding Norovirus).

Communicate and facilitate hospital management of the outbreak

A member of the IPCT will communicate all ward closures to all individuals listed in 6.1.

6.1 The Sector IPCT will inform (Acute inpatient sites) :

Designation	Who	Include in e-mails / Communication Group
SCN and Nurse in Charge in affected areas.	Sector IPCT	Green and above
Consultant in Charge (acute only)/ Receiving Consultant and Lead Clinician	Sector IPCT	Green and above
Bed Manager	Sector IPCT	Green and above
Chief of Medicine	Sector IPCT	Green and above
Chief of Nursing	Sector IPCT	Green and above
Lead Nurse	Sector IPCT	Green and above
General Manager	Sector IPCT	Green and above
Site Manager or Facilities Manager Domestic Services Manager Estates Manager	Sector IPCT	Green and above
Board Infection Control Manager	Sector IPCT	Green and above
Co-ordinating Infection Control Doctor	Sector IPCT	Green and above
NHSGGC Communications	IC Data Team ICM/CICD/ ANDIPC/ Chair of OCT	Green and above
Associate Director of Nursing , Infection Prevention and Control	Sector IPCT	Green and above
Public Health Protection Unit	Sector IPCT	Green and above
Nurse Bank	Sector IPCT	Green and above
Hospital at Night Co-ordinators	Sector IPCT	Green and above
Antimicrobial Pharmacists/Team	Sector IPCT	Amber and above
Occupational Health Service	Sector IPCT	Amber and above
Nurse Director (Acute)	Sector IPCT	Amber and above
Risk Manager	Sector IPCT	Amber or above
Clinical Director (Service)	Sector IPCT	Amber and above
Acute Director	Sector IPCT	Amber or above

Out of Hours – The Consultant Microbiologist on-call will close the ward and inform the IPCNs but it will be the responsibility of the Nurse in Charge to inform the Site Co-ordinator and on-call Manager

6.1(b) The IPCT will inform (Partnerships In-Patient sites):

Designation	Who	Include in e-mails / Communication Group
SCN and Nurse in Charge in affected areas.	Sector IPCT	Green and above
Consultant in Charge/Medics	Sector IPCT	Green and above
Bed Manager	Sector IPCT	Green and above
Lead Nurse/ Inpatient Services Manager Professional Nurse Advisor (Sector) Professional Nurse Advisor (HAI Lead)	Sector IPCT	Green and above
General Manager	Sector IPCT	Green and above
Site Manager or Facilities Manager Domestic Services Manager Estates Manager/ Operations co-ordinator	Secotr IPCT	Green and above
Board Infection Control Manager	Setor IPCT	Green and above
Co-ordinating Infection Control Doctor	Sector IPCT	Green and above
NHSGGC Communication	IC Data Team ICM, CICD/ ANDIPC/ Chair of OCT	Green and above
Assosiate Nurse Director, Infection Prevention and Control	Sector IPCT	Green and above
Public Health Protection Unit	Sector IPCT	Green and above
Nurse Bank	Sector IPCT	Green and above
Antimicrobial Pharmacists/ Team	Sector IPCT	Amber and above
Occupational Health Service	Sector IPCT	Amber and above
Board Nurse Director and Nurse Director (Partnerships)	Sector IPCT	Amber and above
Risk Manager	Sector IPCT	Amber and above
Clinical Director (Service)	Sector IPCT	Amber and above
CHP Director	Sector IPCT	Amber and above

Out of Hours – The Consultant Microbiologist on-call will close the ward and inform the IPCNs but it will be the responsibility of the Nurse in Charge to inform the Site Co-ordinator and on-call Manager

6.2	Board Infection Control Manager / Co-ordinating Infection Control Doctor or	Associate Nurse Director Infection Prevention and Control will inform:

NHSGGC Directors and External Agencies (AMBER and above)

Designation	Who:
Director Public Health	by PHPU
Medical Director / CEO / COO (Acute)/ CHCP Director/Director of Nursing	ICM / CICD / ANDIPC
Health Protection Scotland	ICM / CICD / ANDIPC
Sector/Directorate Director	ICM / CICD / ANDIPC
Others as necessary: Food Standards Agency (FSA), Local Water Authority, Health & Safety Executive (HSE)	PHPU

6.3	NHSGGC Communications Officer will:

Liaise with the Press Offices at Scottish Government Health and Social Care Directorates (SGH and SCD).

6.4	OCT

From those informed in Section 6.1 an OCT will be convened. The primary goals of the OCT are to:

Control the outbreak.

Prevent further spread of the disease.

Investigate the cause and identify factors that contributed to the outbreak, in order to develop and implement measures to prevent similar outbreaks in the future.

Communicate information to patients and the public as required.

For Norovirus, an OCT would only be convened after three ward closures at the same time in any one hospital site.

6.5	OCT Meetings

The OCT will hold meetings regularly until the outbreak ceases. The team will review the hypothesis, control measures, HIIAT and other actions initiated by the IPCT. Minutes will be kept of all meetings.

6.6	Chairing the OCT

An OCT within a hospital setting should normally be chaired by the member of the hospital staff most suitably qualified for the task. Normally this would be the Infection Control Doctor (ICD) or a suitably qualified microbiologist or nominated Service Representative. Ideally, the ICD / Consultant Microbiologist should lead this investigation and take responsibility for completing the final report and ensuring that recommendations are brought to the attention of the Senior Management Team (SMT) for the service affected and the relevant Control of Infection Committee. For outbreaks which have wider public health protection implications, or where there is any other reason why the hospital involved would not be able to chair the OCT, the chairing of the OCT should be discussed and agreed with the Consultant Public Health Medicine (CPHM).

6.7	Reporting the Outbreak

The lead IPCN for the sector will be responsible for logging any outbreaks that require the convening of an OCT onto the Significant Incident Reporting System (Datix) (excluding Norovirus) when the Outbreak is declared over and the OCT report has been approved.

6.8	Formal report of the OCT

The outbreak report will be written by the Chair of the OCT and approved by the OCT. Once the report is approved by the OCT it should be disseminated to the members of the OCT and to: Acute Infection Control Committee (AICC) / Partnership Infection Control Support Group (PICSG), Director of the Service or CHP affected, and the Board Infection Control Manager and Board Infection Control Committee (BICC) as appropriate.

Suggested template of OCT Report:

OUTBREAK DESCRIPTION:
Date outbreak recognised / declared:
Date outbreak declared over:
Setting where outbreak occurred:
Numbers of patients involved:
Number of HCWs involved:
Number of others involved:
Case definition used:
Description of those involved (epidemiology):
Consequences of outbreak to patients, staff and HCWs:
Consequences as a result of the outbreak:
Causative organism:
Mode of spread:
Any other additional contributing factors:
Initial control measures:
Initial reporting:
Spread after initial control measures were instigated:
Further control measures:
Actions recommended to prevent recurrence (including timescale):	What
Who
When
Legal and regulatory action (e.g. RIDDOR, PF referral):
Number of Meetings:
Number of Press Reports during outbreak:
Debrief undertaken
Actions agreed completed and date

Instructions for a closed ward: Infection Prevention Control Advice

Due to a possible outbreak of ___________________________ Ward ________________ has been closed to admissions and transfers effective from __________________ and will remain closed until a member of the IPCT re-opens it.

Please follow the advice that has been ticked

1	Do not transfer any patient out of the ward to nursing home or other clinical area without discussing with a member of the IPCT.
2	Arranged visits / appointments to other departments and with other specialties, e.g. social workers, should be discussed with a member of the IPCT.
3	If a patient requires emergency admission or transfer to another clinical area please inform and discuss with a member of the IPCT.
4	Discharges home are permitted provided the patient’s family is aware of all the necessary precautions and any risk to themselves. This should be documented in patient notes.
5	Limit HCWs movement between this ward and other wards and departments.
6	Remind all HCWs the importance of compliance with the Hand Hygiene Policy. Advise relatives on the importance of hand hygiene precautions.
7	Complete an IPC Care Plan if available.
8	HCWs coming into contact with symptomatic patients and / or their environment must wear appropriate Personal Protective Equipment (PPE). Decontaminate hands after removing PPE.
9	All equipment used on symptomatic patients should be cleaned in between patients and at least twice daily using chlorine based detergent.
10	Patients should be nursed in isolation or in designated cohort areas on advice of the IPCT. Patients if possible should be allocated their own equipment, e.g. commode or toilet.
11	Record all symptoms in relevant nursing documentation, e.g. stool chart (diarrhoea should be assessed using the Bristol Stool Chart), fluid balance chart, wound assessment charts, etc.
12	Inform the IPCT of any new patients or HCWs with symptoms.
13	Complete and update Patient Lists as requested by the IPCT.
14	Environmental Cleaning should be increased to twice daily as per SOP. Domestic staff should pay particular attention to frequently touched surfaces, e.g. bed tables, lockers and toilet areas.
15	Patients should be offered hand hygiene facilities after using the toilet and before meals.
16	Ensure specimens are clearly labeled with relevant patient information including clinical history.
17	Provide patients and relatives with information as appropriate, and document in nursing / medical notes.

Your ward will be reviewed again by a member of the IPCT on ______________. Should you need any further advice the IPCT are available Monday to Friday, normal working hours, and can be contacted on extension ______________ or page __________ Outwith these hours, advice can be obtained from the on-call Microbiologist.

Issued by	_______________________________ Date _________________

Received by	_______________________________ Date _________________

IPCN Name (print)	______ ________________________

SCN Name (print)	______ ________________________

9.	Suggested Agenda for First OCT Meeting

Apologies

Agree person to chair

Confirm membership

Confirm confidentiality

Confirm outbreak

Review of the outbreak to date / cases

Case definition

Number of cases to date (general condition)

Agree HIIAT classification

Early control measures – effect and impact

i) Infection Control Actions

Epidemiology associations with time, place and person

Hypothesis

Additional measures to be taken

Communication

i) To patients relatives and staff

ii) Media

iii) Within NHSGGC

iv) HPS

Additional Resources

Agree action plan

AOCB

Date and time of the next meeting

For subsequent meetings include further cases after instigation of control measures.

10.	Staff Screening

Decisions to screen staff will be taken by the OCT after careful consideration of all risks and benefits. Incidents or outbreaks of infection are particularly stressful and challenging for all staff. It is critical that staff are supported throughout this process and that a culture of blame has no place in NHSGGC.

Rationale for Screening

The rationale for embarking on a staff screening programme must include one or more of the following:

To characterise the epidemiology of the outbreak – time, place, person.

To identify the likely source and index case, with a view to control.

To assist with interrupting the chain of transmission of an outbreak.

The final decision to screen, including which staff group to be included, will rest with the OCT. The rationale for screening and staff groups to be screened must be stated in the minutes.	View the NHSGGC Staff Screening Policy which MUST be followed.

11.	The Hospital Infection Incident Assessment (HIIA)Tool

Hospital Infection Incident Assessment (HIIA) Tool (Watt Risk Matrix Replacement)

Objective: To provide all those who manage and need to know about hospital infection incidents with a simple impact assessment tool.

Step 1 – Assess the infection impact on: Patients, Services, Public Health and Public Anxiety as Minor, Moderate or Major

Patients	Services	Public Health	Public Anxiety*
Minor	Only minor interventional support needed as a consequence of the incident. No mortality.	No, or only very short term closure of a clinical area(s) with minor impact on any other service.	No, or minor implications for public health.	No significant increased anxiety or concern anticipated.
Moderate	Patients require moderate interventional support, but no mortality as a consequence of the incident.	Short term closure(s) having moderate impact on some services, e.g. multiple wards closed or ITU closed.	Moderate implications, i.e. there is a moderate risk of only moderate impact infections to other persons.	Increased concern and or anxiety anticipated.
Major	Life threatening illness or death as a consequence of the incident in one or more patient.	Significant disruption and impact on services, e.g. hospital closures for any period of time.	Significant implications for public health, i.e. there is a moderate or major risk of major infection to someone else.	Alarm within at least some areas of the community anticipated.

Step 2 Calculate the Impact: All Minor = GREEN; 3 Minor and 1 Moderate = GREEN; No Major and 2-4 Moderate = AMBER; Any Major = RED;

Step 3 Take actions are in line with HIIA Tool colour

GREEN	AMBER	RED
Manage within the NHS Board. Log on SHORS if an outbreak. Inform CPHM.	Report to SGHD. Engage with CPHM. Log on SHORS and report to HPS if an outbreak. Ask HPS for support if required** Consider issuing press statement (prepare holding statement)***	Report to SGHD. Engage with CPHM. Report HPS** Log on SHORS if an outbreak. Issue press statement***
* Public Anxiety: If a press statement was released today summarising the situation what would be the likely impact on public anxiety. **Consider others who may be of assistance in managing hospital infection incidents: Food Standards Agency, Scottish Environmental Protection Agency (SEPA), Water Authority, Dental Public Health Consultant, Health and Safety Executive, etc. *** The outbreak status should be confirmed prior to a press statement being issued – this should take no longer than 24 hours. As far as is practicable, patients and elatives should be informed of an incident prior to press statement release. All press statements should be shared with SGHD and Health Protection Scotland.

HPS: October 2011

12.	Evidence Base and Regulations

CNO (2010) 1 National Support Framework for NHS Boards.

Food Standards Agency (Scotland) / SEHD – Guidance on the Investigation & Control of Outbreaks of Foodborne Disease in Scotland – May 2002. GUIDANCE 2002 - Amendment No.8 – May 2006.

Hospital Infection Incident Assessment (HIIA) Tool. Health Protection Scotland. 2011

Standard Operating Procedure for Using the NHSScotland Hospital Infection Incident Assessment (HIIA) Tool. Health Protection Scotland 2009.

Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS led Incident Management Teams – October 2011 (updated July 2013)

NHS HDL (2006)31 Healthcare Associated Infection – Human Resource Policy for Staff Screening During Incidents and Outbreaks. Scottish Government Health Directorates.

Public Inquiry into the outbreak of Clostridium difficile in Northern Trust Hospitals, Northern Ireland. March 2011.

Vale of Leven Hospital Enquiry Report. November 2014

Appendix 1 – Acute Division Ward Closure

When an outbreak is identified the IPCT will close the ward to new admissions and transfers. In order that the potential effect of ward closure on the operational capacity of the hospital can be managed, the Bed Manager and Clinical Service Manager / General Manager of the relevant service need to be notified immediately. They will review capacity and if there are significant concerns, consult the on-call Consultant, Senior Nurse and the A&E Consultant. If necessary the Escalation Policy for identified bed pressures will be implemented in order to identify extra capacity to cope with emergency pressures.

In the event that insufficient capacity can be identified, the on-call Consultant and the A&E Consultant will review the status of patients in the system that have yet to be allocated a bed. If significant safety concerns are identified whereby a patient will be placed at risk by not being admitted to a bed, the on-call Consultant will liaise with the ICD / on-call Consultant Microbiologist and the relevant senior manager to discuss the risk/ benefit issues of admitting the patient to the closed ward. It is understood that the ICD / on-call Consultant Microbiologist will not be expected to change their advice regarding the closed status of the ward but where possible a decision will be reached that both doctors agree is reasonable under the circumstances. Where there is failure to agree the decision will be escalated to Director / Associate Medical Director level.

If a patient has to be admitted to a closed ward area the patient and relatives must be informed that the ward is closed and the risks explained before admission. This must be documented in the patient notes.

Appendix 2: Managing patients with viral gastroenteritis in wards with 100% single side rooms with en-suite.

NHS Greater Glasgow and Clyde has a number of wards with 100% single side rooms with en-suite facilities. It is envisaged that on these wards, it may be possible to successfully contain the spread of certain pathogens such as viral gastroenteritis by implementing enhanced IPC precautions without ward closure.

Where 2 or more patients fit the case definition of HAI viral gastro-enteritis, the IPCT with the clinical team should determine if enhanced IPC precautions should be used rather than closing the ward. Consideration must be given to the following:

- The probability of the symptomatic patients having viral gastroenteritis

- The ability of staff to manage the two or more cases and apply TBP at all times

The enhanced precautions for symptomatic patients are as follows:

A) Twice daily environmental clean with a chlorine based detergent.

B) Dedicated equipment as far as practicable which is subject to cleaning twice per day with a chlorine based detergent.

C) Door to patient’s room is closed at all times (or daily risk assessment documented in patient’s notes) with door sign.

D) Patients are not transferred to any other ward until they have been asymptomatic for at least 48 hours OR on the advice of the IPCT.

E) If patient to be transferred on clinical grounds, staff should contact receiving department to inform them of patient’s condition prior to transfer.

F) Patient should be encouraged to use the ensuite in the room. If not possible, each patient should be given a dedicated commode which stays in their room.

G) Loose stools care plan and Bristol stool chart should be kept up to date while patients are symptomatic

H) As well as PPE and Hand Hygiene SOPs, the staff dress code and Uniform Policy should be implemented at all times.

I) All other patients in the ward should be closely monitored for signs and symptoms as per case definition by ward staff.

J) Visitors to affected patients should be provided with information as per the Loose Stools SOP. They must not be allowed to use other areas of the ward or visit other patients in the ward.

K) Causative organism: It is important to establish a causative organism by sending appropriate specimens i.e. separate samples for C&S and Virology, as early as possible. Stool samples should be sent for C&S and virology, vomit sample can be sent for virology only.

L) If staff cannot be allocated to specific patients, consideration should be given to ward closure (HPS, 2014). Staff on the affected ward must not be allocated to work on unaffected wards.

M) Ward and peripatetic staff should keep an up to date list of symptomatic patients as they would for an outbreak.

N) The IPCT will report this ward as they would for a closed ward with daily updates until patients are no longer infectious.

O) Patients who are deemed a ‘case’ can be discharged home but not to a care home.

Observation by IPCT

The IPCT in conjunction with the clinical team will observe the ward and patients for at least 48 hours from start of symptoms of second case. If no new cases develop in this time, the enhanced precautions should continue with daily review by the IPCT until patients become asymptomatic or are discharged home. If a new case develops despite enhanced precautions in place, this may be evidence of ongoing transmission and consideration must be given to closing the ward as per NHS GGC Outbreak Policy.

NB: The IPCT for NHS GGC will continue to monitor this strategy and review as part of the IPC Policy/SOP audit process.