Policy for the management and control of diarrhoea and vomiting

POLICY FOR THE MANAGEMENT AND CONTROL OF 

DIARRHOEA AND VOMITING (NOROVIRUS) INFECTIONS 

Authorities 

Author: 

Sponsor: 

Reviewer(s): 

Approval 

body: 

Dr R Parnaby 

Consultant 

Microbiologist 

Paula Shobbrook, 

Director of Infection 

Prevention and Control 

Document Control Information 

Type: 

Scope: 

Policy 

Major 

Trust 

CP101 

Reference 

Number: 

Issue Number: 2 

Infection Prevention & 

Control Committee 

Policy Approval Group Status: Published 

Effective Date: July 2011 

Review Date: July 2014 

Disposal Date: 2034 

Document Authorisation Control 

Prepared By: 

Dr Parnaby 

Consultant Microbiologist 

Authorised Officer 

Chris Gordon 

Acting Chief Executive 

Signature: 

Signature: 

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Sponsor: Members of the Infection Prevention & Scope: 

Major 


Reference: 

CP101 


Date July 2011 Status: Published 

Page 1 of 26

Winchester & Eastleigh Healthcare NHS Trust 



DOCUMENT CONTROL 

Document Amendments 

Number Details By Whom Date 

1 Reformatted into Trust format to meet NHSLA 

standards with added notes to training, 

compliance, Trust policy references, and roles 

Steven Jennings 

Divisional 

Governance Lead 

2 3 yearly review IPC Team (lead 

author Sue Dailly) 

6 June 

2008 

February 

2011 

Review Timetable 

Date Reason By Whom Date 

Completed 

2011 3 year review Sue Dailly Lead July 2011 

Nurse Infection 

Prevention & 

Control Team 

2014 3 year review IPC team 

Distribution List 

No Title 

1 All employees via the Winchester and Eastleigh Healthcare NHS 

Trust Intranet 

2 The public via Winchester and Eastleigh Healthcare NHS Trust 

Website 

RELATED TRUST POLICIES 

OP001 Policy for Management of Controlled Documents 

CP073 Hand hygiene Policy 

CP008 Incident Management & Reporting Policy Including the Management 

of Serious Untoward Incidents 

CP076 Policy for the Standard Precautions and PPE (Personal Protection 

Equipment) 

CP030 Overarching Decontamination Policy 

CP077 - Policy for Ward Closure due to an Infection Control Issue 

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CP021 Surveillance Policy (includes reporting of healthcare associated 

infections to the Health Protection agency) 

CP033 (NP 14) Policy for Standards for Record Keeping by Nurses and 

Midwives 

CP071 Major Outbreak Plan 

CP022 Isolation and Infectious Diseases Policy 

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Contents 

Section Title Page 

1 Purpose 5 

2 Scope 5 

3 Roles and Responsibilities 5 

4 Introduction 6 

5 Signs and Symptoms 7 

6 Transmission 7 

7 Diagnosis 7 

8 Patient Management and Treatment 8 

9 Documentation 9 

10 Stool Samples 10 

11 Isolation 11 

12 Hand hygiene 12 

13 Personal Protective Clothing 12 

14 Movement of Affected Patients 12 

15 Environmental cleaning 14 

16 Visitors 14 

17 Staff 15 

18 Ward Closure 16 

19 Outbreak Control Group 16 

20 Monitoring Compliance and Effectiveness 17 

21 Major Outbreak Control 17 

22 Training Implications 18 

23 References 18 

Appendix 1 Diarrhoea & Vomiting Action Plan for Wards 19 

Appendix 2 

NHS South Central Top 10 tips to help prevent 

outbreaks of Norovirus 

21 

Appendix 3 Equality Impact Assessment Tool 26 

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POLICY FOR THE MANAGEMENT AND CONTROL OF DIARRHOEA AND 

VOMITING (NOROVIRUS) INFECTIONS 

1 PURPOSE 

1.1 This policy has been developed to provide a practical document to equip all 

healthcare staff at Winchester & Eastleigh Healthcare NHS Trust (WEHCT) 

with the necessary information on the recognition, management and 

treatment of outbreaks of diarrhoea and vomiting such as Norovirus. 

2 SCOPE 

2.1 This policy extends to cover all WEHCT NHS Trust staff. This policy will also 

apply to honorary contract holders and staff employed by other organisations 

who work with the WEHCT NHS Trust patients and for the Trusts’ other staff. 

2.2 This policy complements professional and ethical guidelines and the Nursing 

and Midwifery Council (NMC) Code of Professional Conduct (NMC 2009). 

2.3 Infection prevention and control is the responsibility of ALL staff associated 

with patient care. A high standard of infection prevention and control is 

required on ALL wards and units, although the level of risk may vary. It is an 

important part of total patient care. 

2.4 It is essential that infection prevention and control is seen as an 

organisational responsibility and priority, that adequate isolation facilities and 

resources are provided, and that appropriate infection control staff and 

support services are available. 

2.5 This policy is ratified in line with OP001 Trusts Policy for the Management of 

Controlled Documents (2007). 

3 ROLES AND RESPONSIBILITIES 

3.1 The Chief Executive (CEO) has overall responsibility for ensuring the Trust 

has appropriate strategies, policies and procedures in place to ensure the 

Trust continues to work to best practice and complies with all legislation. The 

CEO has overall responsibility for the provision of adequate funding to meet 

the increased costs of outbreaks of Norovirus and adequate isolation facilities 

to enable national guidance on the control of Noroviruses to be implemented. 

3.2 Line managers 

3.3 Are responsible for ensuring this policy is accessible for all staff and that they 

have read and understood the content. Line mangers are responsible for 

ensuring any changes in practice are implemented, and any further training 

needs identified and addressed. Ward managers are to assist with the root 

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POLICY FOR THE MANAGEMENT AND CONTROL OF DIARRHOEA 

AND VOMITING (NOROVIRUS) INFECTIONS 

cause analysis which will be carried out following a ward closure or death due 

to Norovirus (see section 20.4). 

3.4 All staff 

3.5 All staff must ensure that their practice follows the current policies. 

Information regarding the failure to comply with the policy (e.g. lack of 

training, inadequate equipment) must be reported to the line manger and the 

incident reporting system used where appropriate. 

3.6 Infection Prevention & Control Team (IPC team) 

3.7 The Infection Prevention & Control Team (IPCT) have a responsibility to offer 

advice to healthcare staff on treatment and isolation requirements. The team 

will collate data and share this within the Trust via the Infection Prevention & 

Control Committee (IPCC) and the Infection Prevention & Control divisional 

leads and link practitioners (IPCLPs). 

4 INTRODUCTION 

4.1 Small round structured viruses (SRSVs e.g. norovirus), are the most common 

cause of outbreaks of gastro-enteritis in hospitals and can also cause 

outbreaks in other settings such as schools, nursing homes and cruise ships. 

Hospital outbreaks often lead to ward closure and major disruption in hospital 

activity. 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. 

4.2 The disease was historically known as the “winter vomiting disease” due to its 

seasonality and typical symptoms. However in recent years this typical 

pattern has changed and outbreaks have occurred throughout the year. In a 

recent study the Health Protection Agency (HPA), have showed that variants 

to the virus emerge frequently and become the predominant circulating strain 

which in turn is later replaced by a new variant. Large numbers of contacts 

can therefore be affected as immunity to the illness is not long-lasting. 

4.3 Norovirus infections are usually associated with relatively mild and short lived 

symptoms and affected individuals in the community rarely seek medical 

attention. However outbreaks involving patients and staff in hospitals can 

have a significant impact on hospital activities ranging from ward closures 

and delays in the admission and discharge of patients. It is therefore 

essential that cases are detected early and isolated appropriately to prevent 

spread and major outbreaks. These viruses are relatively resistant to alcohol 

gel so soap and water must be used when washing hands. 

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5 SIGNS AND SYMPTOMS 

5.1 The average incubation period for norovirus associated gastro-enteritis is 12- 

48 hours. Patients cared for in bays where other patients have symptomatic 

Norovirus may have an extended incubation period and develop symptoms 

after 48 hours of contact with a source of the virus. 

5.2 The illness is characterized by a sudden acute onset of: 

 

 

 

Vomiting (may be projectile) 

Watery diarrhoea and abdominal cramps 

Nausea 

5.3 In addition headache, myalgia, fever and malaise are common. Some or all of 

the above symptoms may be present. 

5.4 Symptoms last between one and three days and recovery is usually rapid. 

The frequency of the symptoms can vary with some patients having just 2-3 

episodes of diarrhoea or vomiting, rather than the expected frequent 

episodes, this depend on the circulating virus at the time of the outbreak. In 

some cases the duration of symptoms may be longer. 

5.5 Dehydration is the most common complication and patients may require 

replacement fluids. 

6 TRANSMISSION 

6.1 Noroviruses are highly contagious with as few as 10 -100 virus particles 

thought to be sufficient to cause infection. Noroviruses are transmitted 

primarily through the faecal –oral route either by person to person spread or 

via contaminated food or water. In addition noroviruses can be spread via 

aerosol dissemination of infected particles following vomiting. 

6.2 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. 

7 DIAGNOSIS 

7.1 Diagnosis of norovirus infection can often be made on clinical grounds from 

their characteristic features. However the infection can also be confirmed 

following testing of a stool sample. 

7.2 When an outbreak is suspected, it is imperative to initiate infection prevention 

and control measures immediately without waiting for virological confirmation 

from stool testing. 

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8 PATIENT MANAGEMENT AND TREATMENT 

8.1 Treatment 

8.2 Currently there is no effective antiviral treatment for noroviruses. It is a self 

limiting illness which will usually cease within a few days. It is important to 

ensure prompt fluid replacement to prevent dehydration and its complications. 

8.3 There is a sample patient, relatives and carer’s information leaflet available 

on the intranet, ref 308 “Norovirus”. Copies of this leaflet are available from the 

IPC team. 

8.4 What to do if you suspect there is an outbreak? 

8.5 If you have 2 or more cases of unexplained diarrhoea and / or vomiting 

or nausea on your ward, either staff or patients, you may be at the start of an 

outbreak. It is the responsibility of the nurse in charge to contact the Infection 

Prevention & Control Team (IPC Team) on ext 4483 or 5170 immediately for 

further advice. (See Appendix 1). 

8.6 Out of hours and during the weekend the nurse in charge must discuss this 

with the on-call Consultant Microbiologist or night site coordinator and either 

email the Infection Prevention & Control Nurses (IPCNs) via their generic email 

address or leave a message on their answer-phone (x5170) so they can follow 

up on the next working day. See 8.9 below for a provisional decision on ward 

closure. 

8.7 There are several different actions which must be taken, some according to the 

number of patients who are affected, but isolation of cases on the same ward 

and prevention of transfers from the ward are both critical. Further, the 

Consultant Microbiologist will make a decision as to whether to close or 

partially close the ward to admissions to bring the situation under rapid control. 

Early discussion is key as every situation is different. Examples of 

requirements for control are as follows: 

a. Move symptomatic patients into side rooms, close the bay for 48 hours, 

consider other patients in that bay as contacts and monitor for 

development of diarrhoea and / or vomiting. Review this with the IPC 

team. 

b. If numbers exceed side room capacity, cohort nurse, symptomatic 

patients and their contacts. Patients with a positive Clostridrium difficile 

result must not be cohort nursed with patients with diarrhoea due to 

another cause. Patients with Clostridium difficile should be moved to the 

cohort ward (Victoria Ward or other ward if so designated in the future). 

c. Send specimens on all affected cases to the Microbiology laboratory. 

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d. Stop all transfers to other wards. 

e. Monitor all unaffected patients for symptom development and affected 

patients for frequency of symptoms. Keep a symptom chart on each 

patient and update on each shift. 

f. Close one or more bays as necessary. 

g. Close the whole ward. 

8.8 The Consultant Microbiologist is the ONLY person with designated 

responsibility to close and open a ward because of infection. Please refer to 

the Ward Closure policy and Major Outbreak Plan for further information. 

8.9 If incidents of diarrhoea and/or vomiting occur during the night, ward staff and 

night coordinator can make a provisional decision to close the bay or ward and 

institute barrier nursing, aiming to collect diarrhoeal samples and then 

contacting the microbiologist or IPCNs in the morning for follow up action. 

8.10 The nurse in charge must inform the site coordinator that there is a problem 

on their ward with diarrhoea / vomiting/ nausea. The site coordinator must 

discuss with the IPC Team what action needs to be taken. 

8.11 The IPCT will visit the ward daily or more often if required to assess the 

situation and set an action plan for the next 24 hours. On a Friday an action 

plan will be set for the weekend or Bank Holiday period. This action plan will 

be verbally discussed with the nurse in charge of the ward and the site 

coordinator. In addition a generic email will be sent out each day from the 

IPCT to all staff on the outbreak contact list to help ensure all relevant staff, 

including the Occupational Health Department, are kept fully informed with the 

latest information. Unexpected events that occur over the weekend or Bank 

Holiday should be discussed with the Consultant Microbiologist on call by the 

site coordinator or on call manager. IPCNs will aim to visit or contact the wards 

at the weekend when outbreaks are affecting several wards within the Trust. 

9.0 Documentation 

9.1 Once an outbreak is suspected the IPCT will ask the ward staff to complete a 

daily record sheet for all symptomatic patients. (See intranet for copies – 

diarrhoea and vomiting outbreaks – data collection form). Patients are most 

infectious during the early stages when diarrhoea / vomiting is profuse. 

Accurate documentation on all symptomatic patients is vital in order for the 

IPCT to make an accurate assessment of the infection and plan the correct 

course of action. The following information is necessary for all symptomatic 

patients: 

i. Name; first and surnames 

ii. Position in ward; state bed number and bay or single room 

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iii. Frequency; please state the number of times the patient has an episode 

of either diarrhoea or vomiting. The data collection form is 

downloadable from the intranet and to be used daily (one sheet per 

day). 

iv. Data should also be collected on patients who are nauseous. It will not 

be necessary to close an area if no vomiting or diarrhoea develops but 

nausea may be an early symptom of infective gastro-enteritis. 

9.2It is the responsibility of the nurse in charge to ensure that accurate 

documentation is maintained on all symptomatic patients throughout the 

duration of the outbreak, as per CP033 (NP 14) Policy for Standards for 

Record Keeping by Nurses and Midwives 

10 Stool Samples 

10.1 Please take a stool sample from every patient who has diarrhoea. If the 

sample is contaminated with urine it can still be sent. Faeces scraped off the 

sheet or incontinence pad can also be used if you are unable to obtain a 

sample from a bedpan. The sample should contain the runniest part of the 

sample. All samples which are liquid will be tested for Clostridium difficile. 

During unsocial hours diarrhoeal samples can be collected for testing during 

the day after discussion with a consultant microbiologist. 

10.2 Stool testing for norovirus is carried out if an outbreak is suspected. It is 

important that a representative number of patients provide samples and these 

are sent to the laboratory as soon as possible. Never wait for positive results 

before implementing infection control precautions and outbreak control 

measures. Viral gastroenteritis is most infectious in the early stages. 

10.3 The IPCT will co-ordinate with the microbiology laboratory to ensure a relevant 

sample of affected patients receives norovirus testing. The current hospital 

laboratory test may confirm some patients have norovirus, but if the samples 

are all negative they will be sent to another hospital laboratory for further 

investigation. This molecular test may become available locally in the future. 

Confirmation of norovirus often is not known until the outbreak is either 

resolving or has resolved if the samples have to be sent to another hospital. 

For financial reasons, once a ward has confirmed norovirus, it is not usual 

practice to continue to test new patients with the same symptoms during an ongoing 

outbreak on that ward. 

10.4 The IPCT will provide the microbiology laboratory with the HPA 

epidemiological outbreak log number to link the outbreak samples which may 

be referred for typing, to the particular outbreak or ward closure which has 

been reported by the IPCT as part of the national enhanced surveillance 

programme for norovirus. 

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11. Isolation 

11.1 Depending on the number of symptomatic patients involved, he/she/they will 

either be nursed in single rooms, or cohort nursed in a bay. Some patients 

cannot be moved to a side room as this would place them in an ‘unsafe’ 

environment. For example patients who are at falls risk, are confused or under 

the Mental Health Act. Consideration must be taken of patients’ clinical and 

psychological needs when assessing where to place patients during an 

outbreak of diarrhoea and vomiting. Please refer to the CP022 Isolation Policy 

for further information. 

11.2 If necessary the whole ward will be closed to admissions, transfers and 

discharges except to the patient’s own home. 

11.3 Patients who have to be moved to another ward due to their clinical 

condition e.g. ITU must be isolated and barrier nursed until symptom free for 

at least 48 hours but ideally 72 hours. The sending ward must inform the 

receiving ward and ensure adequate facilities are provided. 

11.4 The nurse in charge must ensure that a sign is placed on the door of the 

isolation room or affected bay alerting all staff and visitors that this is an 

isolation area. If the whole ward is closed a sign should be placed on the door 

at the entrance to the ward informing staff and visitors of the situation and 

asking them to report to the nurse in charge before seeing a patient. 

11.5 The affected bay or ward should be closed to all new admissions or 

transfers unless approved by the consultant microbiologist. If the clinical 

condition of a patient dictates that their treatment requires them to be admitted 

to a ward closed with diarrhoea and vomiting, the admitting medical team have 

a responsibility to inform the patient of the ward status and also document in 

the patient’s notes that their clinical condition outweighs their risk of entering a 

ward which is currently closed due to diarrhoea and vomiting. 

11.6 When a patient has had no diarrhoea or vomiting for 72 hours they are 

deemed no longer infectious. A ‘closed’ bay can be re-opened when there 

have been no new cases and all affected patients have been asymptomatic 

for 72 hours. When a whole ward has been closed, bays may be opened 

gradually towards the end of the outbreak. Bays can only be re-opened when 

there have been no new cases and all affected patients have been 

asymptomatic for 72 hours. All areas must be deep cleaned or ideally 

decontaminated using hydrogen peroxide technology (Bioquell®) before 

opening, please refer to section 15.0 on environmental cleaning. The 

decision to re-open an infected ward can only be made by the consultant 

microbiologist. In some circumstances the Consultant Microbiologist may 

reduce the 72 hour limit to 48 hours but this decision cannot be taken without 

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his/her advice and agreement. If appropriate the Consultant Microbiologist 

will seek advice from the HPA. 

11.7 All linen from isolation areas should be treated as infected linen and disposed 

off as per the infected linen policy. 

12 Hand Hygiene 

12.1 The hands of healthcare staff can provide the vehicle for the transmission of 

this infection. Furthermore a lack of hand hygiene among healthcare staff is a 

well recognised problem nationally. It is therefore essential that all staff wash 

their hands when required using the correct hand washing technique to help 

reduce the risk of transmission, as per CP073 Hand hygiene Policy. A 

12.2 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 after 

contact with potentially infectious equipment, furnishings or other fomites. 

Please refer to CP073 Hand hygiene Policy for further details. 

12.3 Wearing gloves do not obviate the need to wash hands. 

12.4 Patients must be provided with the opportunity to wash their hands or use 

hand wipes after each toileting episode and also before each meal. Hand 

washing with soap and water is always preferable. 

13 Personal Protective Clothing 

13.1All staff must put on a yellow plastic apron and non-sterile gloves before 

entering an affected bay or side room. These should be removed and hands 

washed with soap and water before leaving the room or bay. Any failure to 

comply with the wearing of protective clothing and hand washing during an 

outbreak should be notified to the ward manager and the IPC team. Failure of 

compliance may constitute a clinical incident. Outbreaks of D&V can be 

contained if all staff follow these instructions. Refer to the CP076 Policy for 

the Standard Precautions and PPE (Personal Protection Equipment) for 

guidance. 

13.2 There is currently no evidence to justify the wearing of face masks routinely 

for either patients or staff. 

14 Movement of Affected Patients 

14.1If a patient is symptomatic, his/her visit to another department should be 

delayed unless clinically urgent, as it will be distressing for the patient if an 

episode of diarrhoea or vomiting occurs during transit. Furthermore this will 

also unnecessarily expose more contacts to the infection and may result in 

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the contamination of equipment e.g. radiological scanners. Alternatives 

should be considered such as portable X-ray. If clinically urgent the 

investigation or treatment should be discussed with the appropriate 

department in advance so that appropriate precautions can be undertaken. 

14.2 Asymptomatic patients in a closed bay maybe able to visit other departments 

for tests etc. It is the responsibility of the nurse in charge of the ward to 

ensure that the receiving department is informed about the status of the 

patient, so they can ensure their visit is brief. 

14.3 Patients in a closed bay or ward who require surgery should have their 

requirements discussed on a case by case basis between microbiologist, 

anaesthetist and surgeon. This will depend on clinical urgency as in 14.1. 

14.4 Asymptomatic patients requiring social work / care home assessment can 

have their assessment carried out in a day room or another room off the 

affected ward so as to reduce the delay in discharge. 

14.5 When Kingfisher ward or another satellite ward e.g. Melbury Lodge has 

norovirus there need to be contingency plans of where these patients will be 

accommodated if they are clinically too unwell to be accommodated on 

Kingfisher ward. The affected ward must discuss with the site coordinator, 

A/E, EMAU and the admitting doctor that the patient either has norovirus or is 

a contact prior to transfer to the RHCH site. 

14.6 What to do if a visit to another department is essential for clinical care 

14.7 Symptomatic and asymptomatic patients must not be transferred to other 

wards. However if the patient needs to be transferred to another ward for 

clinical reasons, this must be discussed with the IPCT on an individual basis, 

and they must be isolated for at least 72 hours following their transfer or until 

symptom free for 72 hours. Individual patients may be transferred to another 

ward to enable them to be isolated. However the nurse in charge or the bed 

manager must discuss this with the IPCT before the transfer takes place. 

14.8 Affected patients must not be discharged to nursing or residential homes until 

they have been clear of symptoms for more than 72 hours. If their discharge 

is planned within this period it is the responsibility of the nurse in charge to 

contact the nursing or residential home to discuss their discharge 

arrangements. The local HPU may advise that a 48 hour interval is 

acceptable. 

14.9 Affected patients may be discharged to their own homes once they are 

deemed fit for discharge. 

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15 Environmental Cleaning 

15.1 Whilst a bay or ward is closed during an outbreak, the area must be cleaned 

twice daily with both detergent and chlorine e.g. Actichlor Plus®. Frequently 

used areas such as toilet areas should be cleaned at least twice daily and 

more frequently should the need arise. It is the responsibility of the nurse in 

charge to inform the housekeeping staff of requirements for their ward. 

15.2 Bays and wards can be re-opened 72 (see 11.5) hours after the last 

symptomatic episode but this maybe reduced to 48 hours if a risk assessment 

suggests this is appropriate. This decision will be made by the Consultant 

Microbiologist. Before opening, all areas on the ward must receive a deep 

clean. This involves cleaning all surfaces with both detergent and chlorine 

e.g. Actichlor Plus® (a combined detergent and chlorine bleach agent), 

paying particular attention to frequently touched objects such as call bells, 

light switches, door handles, taps and toilets. 

15.3 Disposable curtains must be changed when visibly soiled and when a bay is 

‘deep cleaned’ at the end of an outbreak. All window curtains must be 

changed as part of the deep clean process and washed at a temperature of at 

least 60°C or dry cleaned. 

15.4 Healthcare staff should wear the appropriate PPE when undertaking the deep 

clean and must have received training in the use of chlorine based agents. 

Refer to the CP076 Policy for the Standard Precautions and PPE (Personal 

Protection Equipment) for guidance. 

15.5 Nursing staff are responsible for ensuring that all equipment is cleaned with 

detergent and chlorine e.g. Actichlor Plus®, in-between each patient and also 

as part of the deep cleaning process before the ward re-opens. Refer to the 

CP030 Disinfection, decontamination of hospital equipment policy for 

guidance. 

16 Visitors 

16.1 Friends and family must be informed that the ward or bay is currently closed 

because of diarrhoea and vomiting. They should be asked to postpone their 

visit or, if essential for personal reasons to make the visit as short as 

possible. No food should be brought in from outside. Visitors should also be 

asked to wash their hands with soap and water on entering and before 

leaving the ward and to refrain from sitting on the bed whilst visiting. Visitors 

can be given the patient, relatives and carers leaflet 083 “Norovirus” which is 

available from the IPC team. In some circumstances the ward may be 

completely closed to visitors. 

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16.2 Posters will be placed at the entrances to the hospital and in the car park to 

There will also be clear signage outside each closed ward including the use of 

large free standing banners. 

16.3 If the outbreak affects several wards or it is felt to be helpful, the 

communications department will arrange for a press release to local papers 

and radio stations, advising people not to visit patients unless necessary. 

17 STAFF 

17.1Symptomatic staff 

Any member of staff who becomes symptomatic whilst on duty must be sent 

home as soon as possible. Any person who becomes symptomatic at home 

must inform their ward manager by telephone. It is the responsibility of 

symptomatic staff to provide a stool sample to rule out other causes of 

diarrhoea. Staff must not return to work until they have been symptom free for 

at least 48 hours and have also returned to normal eating and drinking habits 

for 24 hours prior to return. 

17.2 Staff can contact the Occupational Health department for specific advice 

e.g. for advice about returning to work. 

17.3 Responsibilities of the ward staff 

17.4 To ensure all members of staff on duty are aware which bays or side rooms 

are infected and what precautions are required. Whenever possible, allocate 

staff to either infected or non-infected areas. 

17.5 To record every episode of diarrhoea and vomiting on a daily record sheet. 

17.6 To take a stool sample from every symptomatic patient. NB sample does not 

have to be a ‘clean’ sample. 

17.7 To promptly update the IPCT if changes in the situation occur. 

17.8 To inform all visitors to the ward that there is an outbreak and advise them 

which precautions are required. 

17.9 To ensure all healthcare staff wear protective clothing when entering an 

affected bay or side room. Any failure to comply with these precautions 

must be reported to the ward manager and if necessary to the IPCT for 

advice. Refer to CP076 Policy for the Standard Precautions and PPE 

(Personal Protection Equipment). 

17.10 To ensure that correct hand hygiene measures are carried out by patients 

and their visitors. Visitors should be discouraged from visiting until all 

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patients in the bay are symptom free, not just the person they are planning 

to visit. If visitors choose to visit a closed bay they should wear gloves and 

aprons and wash their hands before entering and leaving. If other patients in 

the same ward are symptomatic, again the visit should be deferred. 

17.11 To ensure there are adequate stocks of gloves, aprons, linen, disposable 

bedpans and vomit bowls. 

17.12 To ensure that any member of staff affected must be sent home 

immediately. 

17.13 Visiting staff e.g. Occupational Therapists (OT), Physiotherapists and 

Social Workers 

17.14 If the patient is symptomatic and the visit is not urgent they should delay the 

visit. If the visit is essential, gloves and aprons should be worn and make 

the visit as brief as possible. Hands must be washed with soap and water 

once PPE has been removed. Visits to the affected ward should be made at 

the end of the shift. If the visiting therapist has to work on an affected ward 

and then carry out home visits he/she should wear scrubs whilst on the ward 

and wear uniform for the home visit. Staff must not sit on the bed but use the 

chairs provided for visitors. Notes, x-rays and other equipment should not 

be placed on the bed. 

Once a patient has recovered from diarrhoea / vomiting their rehabilitation 

and therapies should recommence. The patient can leave the ward or visit 

the OT kitchen area when 48 hours symptom free. 

17.15 Bank & Agency staff 

17.16 Where possible bank staff should only work on an affected ward or non 

affected ward but not on both. Bank staff can work on a ward affected by 

diarrhoea and vomiting BUT cannot move straight to another ward without 

first ideally showering and at a minimum changing their uniforms. If 

avoidable, staff should work on unaffected wards first then the affected 

ward. 

Agency staff are not permitted by the agency to work on a ward closed with 

diarrhoea / vomiting. 

18 Ward closure – refer to CP077 - Policy for Ward Closure due to an Infection 

Control Issue. 

19 Outbreak Control Group – refer to CP077 Ward Closure policy / CP071 

Major Outbreak Plan. 

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Dr Parnaby 

Type: 




Major 


Reference: 

CP101 







19.1The front reception desk must be kept up to date with which wards are closed 

or affected by diarrhoea/vomiting so they can advise visitors entering the 

hospital. 

19.2 Switchboard must also be informed which wards are affected with diarrhoea 

/ vomiting. 

20 MONITORING COMPLIANCE AND EFFECTIVENESS 

20.1 During the outbreak the IPCT will keep a record of the number of patients 

and staff that were affected and also how long a bay or ward was closed to 

admissions due to infection. 

20.2 Every ward closure is reported internally (on Datix) and an outbreak as a 

Serious Incident Requiring Investigation (SIRI) in line with SIRI reporting 

guidance. These are then reported to the SHA and PCT commissioners or to 

any subsequent commissioning organisation, as required. Any ward closure 

due to suspected norovirus is also reported to the HPA via its electronic 

surveillance scheme. See CP021 Surveillance Policy for further details. 

20.3 An outbreak is a clinical incident and should be reported as such by the ward 

manager or IPCT. Outbreaks may be subject to a Root Cause Analysis 

(RCA), to ensure lessons learnt can be disseminated throughout the 

organisation. See CP008 Incident Management & Reporting Policy including 

the Management of Serious Incidents Requiring Investigation for information. 

20.4 After the outbreak has resolved the IPCT will assist or be responsible for 

writing a summary of the event including lessons to be learnt. This will be 

sent to the Patient Safety and Governance Committee or clinical risk coordinator 

for dissemination. If appropriate an incident review meeting will be 

held. 

20.5 The IPC team will present a summary of the outbreak at the Infection 

Prevention & Control Committee and at divisional meetings so that any 

learning can take place. 

20.6 After each outbreak the practices and procedures around handling the 

outbreak will be reviewed and any changes made and communicated. 

21 MAJOR OUTBREAK CONTROL 

21.1 If two are more wards are affected with the same symptoms concurrently, the 

major outbreak plan may be implemented. Please refer to CP071 Major 

Outbreak Plan for further information. 

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Author: 

Dr Parnaby 

Type: 




Major 


Reference: 

CP101 







22 TRAINING IMPLICATIONS 

22.1 Infection Prevention and Control training on basic principles is part of the 

Trust wide mandatory training scheme for all staff and is monitored via 

attendance records. 

22.2 Training is offered to all staff at induction. 

22.3 Training is offered to all staff at their annual update. 

22.4 Speciality based training is offered via divisional meetings on an ongoing 

basis. 

22.5 The Infection Prevention & Control Link Practitioners participate in the 

specialist programme of ongoing training. 

22.6 It is the responsibility of individuals and line managers to ensure attendance 

training. The Education and Training Department feed back non attendances 

to their respective line managers whose responsibility is to follow up non 

attendances and to ensure their subsequent attendance. 

22.7 E-learning for infection control is an acceptable alternative on alternate years 

once face to face induction is completed. E-learning is accompanied by 

certification which can be used in evidence at appraisal. 

23 REFERENCES 

Health Protection Agency 2007 Newsletter 1. 1 st July Health Protection Agency 

Network for the Detection and Characterisation of Noroviruses. 

Infection Prevention Society (2011) Guidelines for the Management of Norovirus 

Outbreaks in Acute and Community Health and Social Care Settings (Draft May 

2011): Bathgate: IPS 

Nursing & Midwifery Council (2009) Record Keeping: Guidance for nurses and 

midwives. London: Nursing & Midwifery Council 

Report of the Public Health Laboratory Service Viral Gastro Enteritis Working 

Group. (2000) Management of hospital outbreaks of gastro-enteritis due to small 

round structured viruses. Journal of Hospital Infection (2000) 45: 1-10. 

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Dr Parnaby 

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Reference: 

CP101 







Appendix 1 

1: Diarrhoea & Vomiting Action Plan for Wards 

1.1 Contact the Infection Prevention & Control Team (IPCT) when there are 2 or 

more patients with unexplained episodes of diarrhoea and / or vomiting. 

1.2 Move affected patients into a side room or into one bay if this is appropriate – 

if in doubt seek advice from the IPCT. The bay(s) should be closed to 

admissions – seek IPCT advice if in doubt. 

1.3 Cohort nursing should be commenced if there are larger numbers of patients 

involved. 

1.4 Take faecal specimens and label, ‘ward outbreak’. NB stool samples do not 

need to be ‘clean’. 

1.5 It is important to record whether the specimens are from staff or from 

patients. 

1.6 Ensure yellow plastic aprons and gloves are being used when entering all 

isolation areas on the ward. Following their removal staff must wash their 

hands with soap and water and not alcohol gel. 

1.7 All linen should be treated as infected and disposed of into an alginate bag 

and then a red laundry bag. 

1.8 Any staff that becomes ill should leave the ward immediately and go home. 

1.9 Staff should not return to work until they have a formed stool, or are free from 

symptoms for 48 hours and are also eating and drinking for 24 hours. 

1.10 Bank staff should not work on an affected ward and then go straight to an 

unaffected ward – ideally there should be an overnight break between 

changing wards, at a minimum they must change their uniform. Agency staff 

are not allowed by their Agency to work on wards affected by diarrhoea / 

vomiting. 

1.11 Patients can only be discharged to their own home. 

1.12 Patients must not be discharged to another institution such as a nursing or 

residential home. 

1.13 Patients must not be transferred to another ward without permission from 

the IPCT. 

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Major 


Reference: 

CP101 







Appendix 1: 2 

2: The Infection Prevention & Control Team responsibilities : 

2.1 The IPC team will visit the affected ward each weekday or more often to 

collect information on the number of patients / staff affected and their signs 

and symptoms. 

2.2. Inform relevant departments each day as appropriate e.g. by sending out an 

–e-mail to all those on the outbreak list (senior manager, housekeeping, 

occupational health, nurse bank, supplies and laboratory staff). 

2.3 Offer support and advice to ward staff and patients 

2.4 Co-ordinate outbreak meetings, if required 

2.5Liaise with site co-ordinators and support decision making processes at regular 

bed management meetings 

2.6Disseminate “lessons learnt” from the review undertaken of an outbreak on its 

completion 

2.7 Assist the communications department with press releases and wider 

communication as necessary. 

Authorities 


Author: 

Dr Parnaby 

Type: 




Major 


Reference: 

CP101 







Appendix 2: 

Department of Health (2010) NHS South Central Top 10 tips to help prevent 

outbreaks of Norovirus (Document adopted from the HPA and NHS 

London Ten Top Tips). London: DoH 

Ten Top Tips for CEO’s, Medical Director & Nursing Director 

1. Ensure you have a nominated individual responsible for the development and 

implementation of your winter / surge plan, this should contain a section to 

manage an outbreak like Norovirus 

2. Maintain high visibility in all clinical and management areas 

3. Ensure roles and responsibilities are clear for the escalation to executive team 

to maintain leadership and control of a rapidly changing situation. 

4. Plan your escalation facilities, where will these be based, what will trigger their 

opening and closure, and how they will be set up. Consider all external 

alternative providers (including private providers) if wards are closed for 

prolonged periods. 

5. Develop communications plan to ensure engagement in the management of 

acute phase, rapid flow of prepared information and updates within the Trust 

and externally to partnership organisation and members of the public. 

6. Develop staffing plans for staff sickness cover, staffing for escalation areas and 

alternative emergency pathways if wards are closed. 

7. Develop plan for site lock down by the Trust Security team (or providers) if 

required, what will trigger this action. 

8. Ensure a focus on business continuity detailing the financial implications for 

reductions in planned activity and increased emergency activity (specify what 

information must be collected during the adverse situation) 

9. Ensure community escalation plans are in place, who are the key points of 

contact to trigger engagement and implementation. 

10.Ensure escalation plans are in place for social services plans, who are the key 

points of contact to trigger engagement and implementation. 

11.Ensure good communication links established with Executives in local acute 

trusts to share plans and support during extreme pressures. 

12.Test your plan before it is required with table top scenario testing, involving key 

people and local partners 

Document adopted from the HPA and NHS London Ten Top Tips 

Top Ten Tips to help prevent outbreaks of Norovirus 

Ten Top Tips for ward nurses 

1. Recognise patients with symptoms of diarrhoea and vomiting and institute 

appropriate care plan and action (no matter how long the patient has been in 

hospital) 

2. Isolate patients with diarrhoea in a side room immediately 

3. Always wear gloves and aprons for direct patient contact if they have vomiting 

or diarrhoea, discard and wash hands before doing anything else. 

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Major 


Reference: 

CP101 







4. Alcohol hand rub is not reliably effective against norovirus so wash your hands 

with soap and water after each contact with affected patients or their immediate 

environment 

5. Discard all food from the surfaces of lockers. All patient food to be located 

INSIDE lockers. Staff food to be located in staff area only. 

6. Inform the ward matron and IPCT as soon as possible when a patient on the 

ward has diarrhoea 

7. If it appears there are 2 cases of vomiting or diarrhoea in the same bay/ward, 

inform the IPCT immediately (at 8am if overnight or the microbiologist on call at 

the weekend) 

8. Diarrhoeal stool samples should be sent to the laboratory for processing 

immediately (virology requesting norovirus, microbiology requesting c&s and C. 

difficile toxin) 

9. Ensure enhanced cleaning of ward and equipment (1% hypochlorite/ sporocidal 

agents/single use equipment where possible) 

10.If you become unwell with diarrhoea or vomiting stay at home (or if it occurs in 

shift, inform senior and go home immediately) and do not return to work until 48 

hours symptom free 



Ten Top Tips for infection prevention & control teams 

1. Ensure annual updates on infection prevention & control to all clinical staff 

include the awareness and importance of diarrhoea management and other 

relevant policies (disseminate top ten tips). 

2. When a ward team informs you of 2 or more cases of diarrhoea or vomiting on 

ward, attend ward and assess all pts for diarrhoea and vomiting on the same 

day and make a decision about bay or ward closure. 

3. If you institute a bay or ward closure activate the incident/outbreak control 

policy 

4. Post “restricted entry” and “infection control” signs on entrance and exit to 

inform visitors and healthcare staff (where possible assign a mobile hand 

washing unit to entrance/exits, if no sink already present) 

5. Inform Bed Management team, Comms team, DIPC, local HPU, local PCT 

infection control lead 

6. Ensure ward staff aware of policies and actions (Disseminate TOP TEN TIPS to 

appropriate groups) 

7. Ensure laboratories aware of potential outbreak and requirements for testing 

8. Ensure cleaning staff aware of outbreak and know the expected cleaning 

regimen; where necessary observe practice and perform audits 

9. Attend ward daily and perform appropriate surveillance (daily line list, daily epicurve, 

daily sitrep to pre-determined parties) 

10.When no new cases have occurred for at least 72 hours and all symptomatic or 

exposed cases are isolated/ cohorted, deep clean and re-open the ward. 

Review the outbreak management and disseminate any lessons learnt from the 

outbreak throughout the hospital. 

Authorities 


Author: 

Dr Parnaby 

Type: 




Major 


Reference: 

CP101 









TTT for bed management team 

1. Inform IPCT if you are aware of 2 or more cases of diarrhoea on a ward at any 

one time 

2. Following IPCT or Microbiology advice close bay or ward as appropriate 

3. Inform Director of Ops/ Performance/Executive team of any problems 

associated with ward or bay closures immediately (including A&E breaches etc) 

4. Do not move patients from affected bays or affected wards without consultation 

with the IPCT (microbiology out-of-hours) unless urgent clinical need. 

5. Do not cohort symptomatic, incubating or unaffected patients without express 

agreement of IPCT. 

6. Patients can be discharged to their own home once clinically stable and take 

consideration of high risk home contacts 

7. Patients can only be discharged to a nursing home from an affected ward if the 

nursing home is aware and able to institute appropriate infection control 

measures. 

8. Attend incident (outbreak/sitrep) control meetings daily/as they occur 

9. Ensure you have a daily list of all affected bays and wards in the hospital 

10.if you become unwell with diarrhoea or vomiting stay at home (or if it occurs in 





Ten Top Tips for DIPC (and on-call manager) 

1. Liaise closely with IPCT and ensure IPC leadership across organisation 

2. Ensure appropriate IPC policies (outbreak management, diarrhoea, 

decontamination, staff health) in place across organisation and that they are 

audited yearly 

3. Ensure IPCT appropriately resourced to carry out duties during 

incident/outbreak 

4. Ensure that enhanced cleaning and decontamination is supported during 

outbreaks e.g. adequate staff, 1% hypochlorite, hydrogen peroxide 

5. Ensure adequate laboratory support (both virology and microbiology) for 

specimen processing and administration during incidents/ outbreaks 

6. Ensure adequate bed and operational management during outbreak 

7. Ensure that information is disseminated across the organisation in a timely 

manner (minimum daily during outbreak) 

8. Ensure that the hospital has an external communications plan (for patients, 

visitors, PCT, GPs, care homes, other hospitals etc) 

9. Ensure that the Executive Team are aware of incident/outbreak and any issues 

brought to their attention 

10.Ensure the relevant data are collected for reporting to SHA/ Winter Planning 

etc. 

Authorities 


Author: 

Dr Parnaby 

Type: 




Major 


Reference: 

CP101 









Ten Top Tips for Modern Matrons 

1. Ensure that your ward staff are aware of Diarrhoea and Vomiting/ Norovirus 

policies and inform IPCT promptly (within 24 hours) of all cases 

2. Ensure adequate clinical care of patients with diarrhoea and vomiting (stool 

charts, fluid intake) 

3. If outbreak is declared ensure IPCT advice is followed by all ward staff and 

visitors (including specialists/clinicians etc.) 

4. Ensure enhanced ward cleaning commences and continues in a timely manner 

(at least twice daily) during outbreak 

5. Restrict movement of ward/bank staff and allocate nursing staff to designated 

affected and unaffected areas during outbreak where possible 

6. Discard all fruit and food items from ward area 

7. Consider use of scrubs for ward staff 

8. Restrict visiting to ward according to hospital policy 

9. Ensure AHPs/ medical staff visit ward/ designated areas last on rounds unless 

patient requires urgent clinical review (and ensure that ward staff understand 

this) 

10.Once outbreak is over, instigate ward deep clean (change all ward curtains, all 

linen items etc) and complete pre-opening checklist 



Ten Top Tips for Facility teams, Cleaners, and Housekeepers 

1. Ensure all staff working in clinical areas are aware of diarrhoea and vomiting 

and related infection prevention and control policies 

2. Ensure all staff attend annual IPC update sessions (for external contractors 

ensure they have appropriate yearly training in place) 

3. Ensure there is an enhanced cleaning policy for ward and rooms during an 

outbreak 

4. Ensure there is a policy for deep cleaning ward and individual rooms after 

outbreak before ward re-opens 

5. Ensure all cleaning staff are aware of specific products to use during diarrhoea 

outbreak (e.g. 1% hypochlorite and hydrogen peroxide) 

6. Cleaners working in affected wards or areas should not take cleaning 

equipment to unaffected areas. 

7. No food or drink is to be consumed in affected areas by ward staff. Breaks and 

meals should be in designated rest areas 

8. Alcohol hand rub is not reliably effective against norovirus so wash your hands 

with soap and water after each contact with affected patients or their immediate 

environment 

9. All waste from cleaning processes to be discarded as potentially infectious 

Authorities 


Author: 

Dr Parnaby 

Type: 




Major 


Reference: 

CP101 







10.if you become unwell with diarrhoea or vomiting stay at home (or if it occurs in 




Authorities 


Author: 

Dr Parnaby 

Type: 




Major 


Reference: 

CP101 







Appendix 3 - Equality Impact Assessment Tool 

To be completed and attached to any controlled document when submitted to the appropriate 

committee for consideration and approval. 

Yes/No 

Comments 

1. Does the policy/guidance affect one group 

less or more favourably than another on the 

basis of: 

Race NO 

Ethnic origins (including gypsies and 

travellers) 

NO 

Nationality NO 

Gender NO 

Culture NO 

Religion or belief NO 

 

Sexual orientation including lesbian, gay 

and bisexual people 

NO 

Age NO 

 

Disability - learning disabilities, physical 

disability, sensory impairment and mental 

health problems 

2. Is there any evidence that some groups are 

affected differently? 

3. If you have identified potential 

discrimination, are any exceptions valid, 

legal and/or justifiable? 

4. Is the impact of the policy/guidance likely to 

be negative? 

5. If so can the impact be avoided? 

NO 

NO 

N/A 

NO 

6. What alternatives are there to achieving the 

policy/guidance without the impact? 

7. Can we reduce the impact by taking 

different action? 

If you have identified a potential discriminatory impact of this procedural document, please refer it to 

the Board Secretary, together with any suggestions as to the action required to avoid/reduce this 

impact. For advice in respect of answering the above questions, please contact the Compliance 

and Governance Manager: Telephone Number: 01962 825376 

Authorities 


Author: 

Dr Parnaby 

Type: 




Major 


Reference: 

CP101

Policy for the management and control of diarrhoea and vomiting

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