Management of In-patients with Loose Stools ... - NHS Lanarkshire

Note: Completion 

of Review 

NHS Lanarkshire 

Health Protection Committee 

SECTION E 1 - Management of In-patients with 

Loose Stools: Gastrointestinal Outbreak 

Section E1 

Effective From Sep 2010 

Replaces Jun 2010 

Pages 1 of 31 

Review Date March 2013 

Health Protection Committee approved review date extension to March 2013 

Guideline Objective 

This guideline aims to ensure that systems are in place to prevent and 

control infection and communicable disease by underpinning national 

polices. It outlines the criteria, responsibilities and systems required to 

manage specific conditions/ infections. The goal of this guideline is to 

protect patients, staff and the public by effective prevention and control of 

infection and communicable disease. 

Compliance with this guideline is best practice. If you have any 

concerns please discuss with your line manager who will consult 

the local Infection Control/Health Protection Team for advice 

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SECTION E 1 

CONTENTS 

Page Nos. 

Management of In-patients with Loose Stools: Gastrointestinal Outbreak: 

Guidelines for the Management of Patients with Clostridium Difficile 

E 1-28 

IS IT A NOROVIRUS OUTBREAK: A DECISION TREE TO HELP 

CLINICAL STAFF 

E 4 

1 MANAGEMENT OF IN-PATIENTS WITH LOOSE STOOLS E 5 

CLEANING SPILLAGES OF VOMIT AND FAECES E 6 

SIGNIFICANT EXPOSURE/CONTAMINATION TO VOMIT & FAECES E 7 

2 GASTROINTESTINAL OUTBREAK E 7 

RECOGNITION OF AN OUTBREAK E 7 

WHEN A SUSPECTED OUTBREAK OCCURS E 8 

CONFIRMATION OF AN OUTBREAK E 8 

DUTIES OF THE NURSE IN CHARGE OF THE AFFECTED AREA E 10 

DUTIES OF THE INFECTION CONTROL TEAM E 11 

IMMEDIATE RISK REDUCTION E 11 

PATIENT PLACEMENT & BED MANAGEMENT E 12 

GENERAL CONTROL MEASURES E 13 

COMMUNITY STAFF E 14 

ENVIRONMENTAL CLEANING E 15 

CONCLUSION OF AN OUTBREAK E 15 

OTHER PRACTICAL POINTS TO CONSIDER FOR CLINICAL AND 

INFECTION CONTROL TEAMS 

E 16 

3 BIBLIOGRAPHY E 17 

Appendix 1 The Bristol Stool Form Scale E 18 

Appendix 2 Specimens E 19 

Appendix 3 Daily Stool Chart E 20 

Appendix 4 Membership of Outbreak Control Team (OCT) E 21 

Appendix 5 Infection Control Outbreak / Episode Risk Matrix E 22 

Appendix 6 Outbreak Record Form (Gastroenteritis) E 23 

Appendix 7 Daily Stool Specimen Form E 24 

Appendix 8 Daily Checklist For Wards E 25 

Appendix 9 Patients with Vomiting and Diarrhoea E 27 

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Appendix 10 Protocol for Cohort Isolation During Suspected or Confirmed 

Outbreaks of Norovirus 

E 28 

Appendix 11 Norovirus Infection Control Staff Information E 29 

Appendix 12 Infection Control Advice in the Care Home Setting E 31 

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Is it Norovirus Outbreak? 

A decision tree to help clinical staff 

Outbreaks can start abruptly and spread quickly – to minimise their impact on patients and the hospital they must be recognised, 

reported and controlled very swiftly. 

This flow chart will help you make the right decision. 

Is there anyone else on the ward (patient or staff) with 

unexplained diarrhoea and/or or vomiting? 

Are two or more of these “Norovirus 

Outbreak Markers” present? 

Symptom onset was sudden 

Vomiting is projectile 

Diarrhoea is watery and not blood stained. 

Symptomatic patients have not had laxatives 

or enemas within past 48hrs. 

Negative stool for C.diff, Salmonella, E.coli 

0157, Cryptosporidium, Shigella and 

Campylobacter. (but don’t wait for results 

before reporting a suspected outbreak). 

YES 

YES 

NO 

YES 

Likely to be a Norovirus Outbreak 

Alert the Infection Control Team 

Isolate the patient or if the number of 

symptomatic patients exceeds available 

single room, cohort isolate 

Send a stool sample to bacteriology and 

virology. 

Contact precautions for all symptomatic 

patients, send symptomatic staff home. 

Start Norovirus Outbreak Data Record for 

all symptomatic cases. 

Refer to Section E Control of Infection 

Manual 

E 4 

NO 

Isolate 

symptomatic 

patients in a 

single room if 

possible, with 

the door closed 

to reduce the 

possibility of 

cross-infection- 

Not an outbreak (yet) 

Isolate the patient where possible. 

Start contact precautions. 

Send a stool sample to 

bacteriology and virology. 

Be extra vigilant for other patients 

or staff developing symptoms. 

Continue to monitor the patients’ 

condition. 

Send symptomatic staff home. 

Less likely to be Norovirus 

Isolate the patient(s) where 

possible 

Use contact precautions 

Send stool samples for culture 

Consider other causes of 

diarrhoea such as antibiotics, 

laxatives, constipation, food 

related etc. 

Call the ICT if you are 

concerned or if the situation 

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1. MANAGEMENT OF IN-PATIENTS WITH LOOSE STOOLS 

Due to the danger of transmission of enteric pathogens and the ease with which pathogens may 

transmit between in-patients in a healthcare setting, it is necessary to have strict guidelines for 

the management of any patient with loose stools. 

A LOOSE STOOL IS DEFINED AS ONE WHICH CONFORMS TO THE SHAPE OF ITS 

RECEPTACLE (FOR VISUAL AID/GUIDANCE REFER TO APPENDIX 1) 

Where any patient develops loose stools: 

Standard/contact based precautions must be implemented (Section C, Control of Infection 

Manual). 

Isolation at this point is not usually required. 

DIARRHOEA IS DEFINED AS THREE OR MORE LOOSE STOOLS WITHIN A 24 

HOUR PERIOD 

Some patients may regularly suffer from diarrhoea, and any variation in the normal stool pattern 

is indicative of a problem and the following should apply: 

Obtain a stool specimen and send it to the Microbiology Department (Appendix 2) 

Commence patient on a formal stool chart (Appendix 3) 

Commence patient on a fluid balance chart 

Continue with Standard/Contact Precautions 

Contact Infection Control Team for further advice 

Where possible, isolate the patient in a single room. If this is not possible then observe 

strict adherence to Standard Precautions. If possible, nurse the patient next to hand washing 

sink and provide them with either a separate commode or toilet 

Inform the Clinician or General Practitioner on duty/on call and inform him/her of the 

situation (where applicable) 

All treatment and precautions implemented must be clearly documented in the patient's 

notes 

Advise that laxative prescriptions must be discontinued where appropriate 

Advise that anti-diarrhoeal medication should not be prescribed 

If a diagnosis of Clostridium difficile is made, refer to Section E2 on Clostridium 

difficile for further information on treatment management 

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If the diarrhoea ceases then the patient may, after being symptom-free for 48hrs, and following 

consultation with the Infection Control Team, be returned to their usual placement. This can be 

carried out prior to confirmation of the laboratory results, provided he/she is continent and can be 

relied upon to maintain good hand hygiene. 

If diarrhoea continues beyond 24hrs, and in the absence of any positive microbiology, two further 

specimens should be sent 24hrs apart, unless advised otherwise by a member of the Infection 

Control Team. 

If these three specimens are negative then, after consulting the Infection Control Team, the patient 

can return to their usual placement even if diarrhoea continues, provided that he/she can maintain 

good hand hygiene. 

If symptoms subside before further samples are obtained then, as above, the patient may return to 

their usual placement after consulting the Infection Control Team. 

If any of the samples test positive the patient may require treatment. Staff must contact the 

Infection Control Team who will give further advice as required. The patient where possible, 

should remain in isolation. In certain circumstances transfer to the Infectious Diseases Unit at 

Monklands Hospital may be indicated. This would only be undertaken after full consultation 

between the Infectious Diseases Physician and the Microbiologist. 

Follow-up (clearance) specimens are not usually required once the acute symptoms have resolved 

and the stool is formed. There are some exceptions to this. For further details please refer to 

Section F, Control of Infection Manual. 

If two or more patients within the same clinical area develop loose stools within 24hrs, with no 

obvious cause, such as laxative administration, suppositories, medicine administration, altered diet 

etc., then the possibility of an outbreak should be considered and must be reported to the Infection 

Control Team. 

CLEANING SPILLAGES OF VOMIT AND FAECES 

The following precautions should be followed by staff when cleaning vomit or faeces. Refer 

also to Section I, Control of Infection Manual Spillage Poster: - 

Wear disposable gloves and plastic aprons. A surgical type face mask may be worn to 

prevent inhalation of contaminated aerosols during this procedure, particularly where a 

patient has vomited. 

Use disposable paper towels to soak up any excess liquid. Transfer these and any soiled 

matter into a clinical waste bag 

Clean soiled area with a solution of detergent and chlorine e.g. Actichlor Plus 

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If visible blood is present, disinfect as per guidelines within Section I, Control of Infection 

Manual 

Clean and rinse off disinfectant with warm water 

Dispose of paper towels, gloves and aprons into the clinical waste bag 

SIGNIFICANT EXPOSURE/CONTAMINATION TO VOMIT/FAECES 

Any member of staff who has had a significant exposure to faecal matter, either by the 

definition below or by having their clothing grossly contaminated, must fill out a DATIX form. 

A significant exposure/contamination to blood/body fluid is defined as a contact of broken skin, 

mucous membrane or eyes with another person’s blood or body fluid. 

2. GASTROINTESTINAL OUTBREAK 

BACKGROUND 

Gastrointestinal symptoms can be caused by numerous factors. Outbreaks within healthcare 

settings are generally caused by viral pathogens most commonly Norovirus, however they can 

be caused by bacterial infections. Outbreaks of viral disease, in particular Norovirus are more 

common during the winter months, they have a short incubation period and usually cause 

vomiting and/or diarrhoea. Other clinical features consist of abdominal pain and a low-grade 

fever. A viral gastrointestinal illness is highly transmissible and is usually passed from person 

to person often by vomit/faecal contamination and is the main cause of outbreaks within 

healthcare settings. 

RECOGNITION OF AN OUTBREAK 

Early evidence of outbreaks of infection may be detected by nursing/medical staff, the 

Infection Control Team or by the Microbiology Laboratory 

It is recognised that there cannot be absolute criteria for defining an outbreak or problem 

and in certain circumstances staff may have to act on the grounds of 'reasonable suspicion'. 

Staff should act promptly and seek advice where there is concern rather than worry about 

'false alarms'. It is much better to be cautious, and to report early, rather than to wait until a 

major problem is evident 

ANY OF THE FOLLOWING IS SUGGESTIVE OF A PROBLEM: 

Any patient with a confirmed laboratory report of a gastrointestinal pathogen such as 

salmonella 

Unexplained diarrhoea in two or more patients within the same 24hr period 

Unexplained vomiting in two or more patients within the same 24hr period 

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Any patient diagnosed as having a food borne illness, whose symptoms developed after 

admission 

A patient whose relatives/contacts have had gastrointestinal symptoms in the last 24 - 48hrs 

WHEN A SUSPECTED OUTBREAK OCCURS 

Any member of staff who suspects that an outbreak may be occurring must as soon as is 

reasonably practicable, report his/her suspicion to the person in charge. The staff must ensure 

standard/transmission based precautions are being observed throughout the ward area (Section 

C, Control of Infection Manual). Where possible, patients should be isolated in a single 

room, or cohort nursed if the patient developed symptoms whilst in a 4/6 bedded bay (see 

Appendix 9). 

The person in charge must then report the possibility of an outbreak, as soon as is reasonably 

practicable to: 

The Infection Control Team (out with office hours, the on-call Microbiologist/Infection 

Control Doctor must be informed) 

The Senior Manager for Nursing responsible for that area 

The Clinician or General Practitioner on duty/on-call 

A member of the Infection Control Team will visit the area (as soon as is practical) and 

communicate with the relevant individuals as to the control measures to be implemented. 

IN THE CARE HOME SETTING 

General care and management of a resident with gastrointestinal symptoms (diarrhoea and 

or vomiting) 

• If any resident has diarrhoea and/or vomiting report this immediately to the person in charge. 

• Check that the resident is not taking prescribed laxatives or any other drugs that could cause 

diarrhoea. 

• Organise stool sampling (appendix 2). 

• As long as this does not compromise their safety, ask any resident who is suspected of having a 

gastrointestinal infection (symptoms of diarrhoea and or vomiting) to remain in their room (with the 

door closed) whilst they are unwell and not to visit communal areas until 48 hours after they are 

symptom free. Those residents who Residents with dementia must be closely monitored 

• Explain to the resident why they need to stay in their room. The resident may feel unhappy at 

being isolated so make sure they can access help easily and are not ignored or suffer as a 

consequence of having the door closed. 

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• Where there is a difficulty in employing isolation measures, such as residents with comprehension 

problems/ dementia, close monitoring is essential to prevent the spread of infection. 

• Monitor the resident closely to make sure they do not become dehydrated (start a stool and fluid 

balance recording chart). 

• As prescribed by the GP, use oral rehydration solutions to prevent or reduce the risk of 

dehydration. Signs of dehydration include loss of appetite, dry skin, dark coloured urine, dry 

mouth, fatigue, headaches and increased respirations. 

• If any resident(s) becomes more unwell as a consequence of the diarrhoea and /or vomiting, report 

this immediately to the GP. 

OUTBREAK CONTROL MEASURES IN THE CARE HOME SETTING 

If there are 2 or more residents or staff with symptoms - a possible outbreak 

• Report this to the person in charge immediately who should seek advice from the NHS Board’s 

HPT (Mon – Friday 9am – 5pm 01698 858232 and Out of Hours 01236 748748), the GP and 

notify Care Inspectorate (01698 208150). 

• The HPT will assess the situation and provide all the necessary advice, including the need for 

daily updatres. The advice can be seen in appendix 12. 

• If any resident requires admission to hospital, inform the clinical area receiving the resident 

and the ambulance/transport service that the resident has/has had diarrhoea and/or vomiting, 

or that there are residents with diarrhoea and/or vomiting in the care home. 

• Do not resume normal admissions of new residents until the NHS Board HPT advises. 

Information for residents and visitors 

• Ensure all residents, relatives and visitors are aware of what they should do in any outbreak 

situation and what they can do to prevent additional personal risk. 

• Provide written information e.g. how to wash personal laundry (refer to Section D) and how to 

wash hands ( refer to Section H). 

• If an outbreak occurs, there should be a management approved notice on the door of the care 

home to alert visitors to the possibility of a norovirus, or diarrhoea and vomiting, outbreak. 

• The notice should advise visitors to speak to the person in charge in order that the following 

messages should be reinforced. Visitors should be advised to: 

• wash and dry their hands on entering the care home, on leaving the care home and not to put 

fingers in their mouth or consume food or drink whilst in the care home. 

• reduce (or avoid) the number of visits whilst the outbreak lasts. 

• refrain form visiting if they themselves are suffering from any gastrointestinal symptoms 

(diarrhoea and/or vomiting) until they are 48 hours symptom free. 

• stop children visiting the care home during an outbreak. 

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CONFIRMATION OF AN OUTBREAK 

A member of the Infection Control Team will immediately initiate such investigations as is 

necessary to confirm the possibility of an outbreak. Following confirmation of an outbreak the 

following communications will take place: 

INFECTION CONTROL TEAM WILL INFORM AS APPROPRIATE: 

The nurse in charge of the affected area 

SALUS Occupational Health 

The Consultant in Public Health Medicine (CPHM) 

Medical Director 

Chief Executive 

Director of Nursing Services 

Facilities/Domestic Services Manager 

General/Service Manager 

Communications Manager 

Bed Manager 

Accident and Emergency 

Acute Receiving Unit 

Scottish Government Health Directorate 

Health Protection Scotland 

Bankaide 

AHPs 

Social Work 

Chief BMS 

THE NURSE IN CHARGE WILL INFORM: 

The Senior Manager for Nursing/Midwifery 

Clinician or General Practitioner on duty/on-call 

Domestic Services 

Other relevant healthcare workers that visit the ward i.e. AHPs, Social Work 

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THE CLINICIAN OR GENERAL PRACTITIONER ON DUTY/ON CALL WILL INFORM: 

Consultant in charge of patients 

THE FACILITIES/DOMESTIC SERVICES MANAGER OR DEPUTY ON CALL WILL 

INFORM (IF APPLICABLE): 

The Domestic Manager/deputy 

Catering Manager 

Estates Manager 

Head of Portering Services 

Where applicable, the decision to close a ward to admissions/transfers will be taken by the 

Infection Control Team, in consultation as appropriate with relevant personnel. 

The Infection Control Team, in conjunction with relevant clinicians, managers and the 

Consultant in Public Health Medicine will jointly decide whether to convene a meeting of an 

Outbreak Control Team (Appendix 4). Depending on the nature and extent of the outbreak, 

and following completion of the "Infection Control Outbreak/Episode Risk Matrix" (Appendix 

5) a decision will be taken whether to initiate the local NHS Lanarkshire Outbreak Plan. 

DUTIES OF THE NURSE IN CHARGE OF THE AFFECTED AREA 

Ensure that the ward doors are kept closed and that an approved notice indicating that the 

ward is closed due to an outbreak of diarrhoea and vomiting, is placed on the ward door 

asking people entering the ward to report to the nurse in charge 

Notify relatives as soon as possible of any restrictions in place 

Other staff groups should be informed of the outbreak situation e.g. ward Clinical 

Pharmacists, Physiotherapists, Occupational Therapists, Social workers etc 

All relevant information for each affected patient must be documented on the Daily 

Outbreak Record Form (Appendix 6). Ensure that ongoing accurate records are maintained 

As soon as possible, a specimen of faeces, or if not possible to obtain a faecal sample, a 

sample of vomit should be obtained from all patients with symptoms. Other specimens may 

be requested at a later date. Staff should complete the Daily Stool Specimen Result Form 

(Appendix 7). It is essential that the accompanying request form is filled in as 

accurately and as comprehensively as possible (Appendix 2) 

Ensure patients, staff and visitors pay strict attention to hand hygiene. A Level Two hand 

wash should be practiced by all staff (Section H, Control of Infection Manual) and 

Standard Precautions adhered to (Section C, Control of Infection Manual) 

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Ensure contaminated linen is disposed of as foul/infected and other materials are handled in 

the correct manner (Section D, I & K, Control of Infection Manual) 

Where staff are affected, ensure that the protocol for employees with gastrointestinal illness 

is strictly adhered to. All symptomatic staff should be referred to SALUS Occupational 

Health 

Ensure that, during outbreaks, staff do not travel to and from work in their uniforms. The 

uniforms should be transported to and from work in a clean polythene bag. If uniforms are 

contaminated by blood/body fluid they must be handled according to the section within the 

Uniform Policy, Guidelines for Staff Laundering their Uniforms at home. 

Issue patients and visitors with an information leaflet on Vomiting and Diarrhoea. Where 

necessary relatives should be issued with leaflet in relation to laundering patients clothes 

Ensure a high standard of cleanliness is maintained at all times throughout the ward 

Ensure that the Aide Memoir Checklist (Appendix 8) is completed and signed off each day 

and returned to the ICT at the end of the outbreak 

DUTIES OF THE INFECTION CONTROL TEAM 

If practical visit the affected area on a daily basis, if not then phone the area daily 

Ensure that staff adhere to outbreak control measures. 

Liaise with the Nurse in Charge/Senior Manager for Nursing and the Microbiologist on a 

daily basis. 

To ensure all control measures are in place, utilise Aid Memoir form within (Appendix 8) 

as a point of reference. This should be left with the Nurse in Charge of the Ward and signed 

off each day 

Where appropriate e.g. Salmonella infection, full food histories should be obtained, in 

consultation with the Consultant in Public Health Medicine, to allow for a more in depth 

analysis to be done. 

Ensure that all the relevant information is collated accurately and that the Daily Outbreak 

Record Form (Appendix 6) is readily available, and fully maintained. 

Ensure the Form (Appendix 8) is fully maintained on a daily basis 

Issue a daily update on the outbreak situation to all relevant parties by e-mail. 

Complete a summary report template on completion of the outbreak 

Conduct a debriefing exercise 

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IMMEDIATE RISK REDUCTION 

If ward pantries or kitchens have doors, these should be closed, and kept closed. 

Identify and advise on the discarding of food throughout the ward which may have been 

contaminated by Norovirus contaminated aerosols (from projectile vomit), e.g. fruit or 

sweets on patient lockers, open butter dishes in pantries. 

Avoid the subsequent exposure of food in the ward, on bed-tables and lockers and in 

pantries / kitchens. 

Review ward equipment and remove any equipment that cannot be effectively 

decontaminated, e.g. damaged commodes or chairs with torn seat coverings. 

Follow guidance within the section of this guideline relating to Cleaning Spillages of 

Vomit and Faeces, page E6, when cleaning equipment or spillages. 

Avoid exposing equipment to airborne Norovirus contamination wherever possible, e.g. 

consider covering open disposables items with plastic sheets. 

Stop using fans in the ward areas. 

PATIENT PLACEMENT AND BED MANAGEMENT 

Patient placement decisions during a Norovirus outbreak require local infection control 

and clinical team assessment of the options with the least risk for all the patients. 

The variables that will assist the ICT and clinical team in making patient placement 

decisions with the best options for patient safety include: the number of symptomatic 

patients, the number of patients who are vomiting, the ward layout (cubicles, beds per 

bays or nightingale ward areas), the availability of commodes, hand hygiene facilities, 

toilets and en suite facilities, the sex mix on the ward, the vulnerability of patients who 

are not currently affected, current occupancy rate and the duration of symptoms. The 

following are guidelines: 

Patients who are vomiting pose most risk – if possible isolate these patients in a single 

room and keep the door closed. 

If there are more symptomatic patients than available cubicles, cohort nurse 

symptomatic patients together in bays. 

Do not move patients if it places asymptomatic patients at risk of exposure. 

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As the number of patients decreases it may be that one or two patients remain 

symptomatic longer than others. When available, these symptomatic patients can be 

moved into single rooms to further reduce spread, and aid containment of Norovirus. 

Patient placement assessments should be done on a daily basis. 

Empty Beds: As patients are discharged, the linen on the beds should be removed and 

the bed, bed table and locker cleaned with neutral detergent and water and then dried. 

During the terminal clean, all empty beds should be re-cleaned and the bed cleaning 

process should include 1000ppm available chlorine. After the terminal cleaning has been 

completed, the beds can then be remade. The rationale for this is that Noroviruses could 

survive for up to a week on cleaned beds and on clean bed linen, and also to prevent the 

need for the double use of hypochlorite solution. 

Create clean bays – as patients are discharged, try to create clean bay areas, where 

patients can be admitted to first once the ward is reopened. 

GENERAL CONTROL MEASURES 

STAFF MOVEMENT 

Nurses/bankaide staff imported into an affected area should not return to work in an unaffected 

area until the outbreak is declared over, following being asymptomatic for fully 48hrs, or fully 

48hr after their last shift working within an affected area. The nurse in charge of the affected 

area must inform the Nurse Bank of any problems ongoing within the ward. Likewise, staff 

working in an affected area should not go to work elsewhere through a nurse bank. 

Physiotherapists and Occupational Therapists should not treat patients unless it is deemed 

essential and so far as is possible, should not go from an affected to an unaffected area. Social 

work staff should liaise with the nurse in charge of the ward in relation to visiting patients. If 

necessary it may be possible to arrange to visit patients in a room away from the main ward 

area. Difficult situations should be discussed with the Infection Control Team. 

PATIENT MOVEMENT 

The ward should be closed to all admissions, and the ward doors should be kept closed, and an 

approved notice should be placed on the door indicating that within the ward there is an 

outbreak of diarrhoea and vomiting and that the ward is closed and to report to the nurse in 

charge. 

Exceptions: In exceptional situations the risk to an individual patient of Norovirus acquisition 

will be less than the risk of non-admission. In such exceptional events, when alternative 

possible accommodation for the patient has been excluded, the patient can be admitted to a 

closed ward, but the patient and relative must be informed of their personal Norovirus risk. The 

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aforementioned should not take place without consulting the Infection Control Team. 

Such events should be recorded via the DATIX system. 

Avoid transferring any patients to other hospital/clinical areas/nursing homes unless there is a 

clinical priority. On occasion where wards are cohort isolating patients, and the ward is not 

closed: patients out with the excluded rooms/bays may be discharged to another healthcare 

facility, providing they have had no symptoms within the previous 48 – 72 hrs, and have not 

been cared for next to symptomatic patients. It is essential that a full risk assessment is 

undertaken by the Infection Control Team prior to transfer, and that the receiving 

ward/area/care home are fully informed of any ongoing issues within the transferring wards. 

Patients should only be admitted to another ward/area/care home if there is a single room 

available to receive the patient into. The patient should remain in the single room for at least 

forty-eight hours. 

Patients can be discharged home providing they are asymptomatic; however the patients GP 

should be informed. 

If patients require investigative procedures the receiving department must be informed, and the 

patient should be scheduled last on the list. 

VISITORS 

Visitors should be kept to a minimum. They must be encouraged to practice appropriate hand 

hygiene, i.e. level 1 (soap & water). Visitors should be advised not to eat the patient's food or 

use their toilet, and any food such as fruit should be placed inside the locker. Ideally, children 

under the age of twelve should be discouraged from visiting. Visitors should be discouraged 

from visiting other patients, whether in the affected area/ward or in wards unaffected by the 

outbreak. 

FOOD HYGIENE 

Staff working for the Catering Department should not directly access the affected ward, the 

trolley/trays being handed over to ward staff at the entrance to the ward. Food trolleys will be 

delivered to the ward and dishes washed in the normal way. 

Under no circumstance should any utensils, crockery, napkins or trays be returned to the 

Catering Department if they are contaminated with vomit. 

Staff serving meals should decontaminate their hands between serving each room. 

Staff must not eat food within the ward environment. 

COMMUNITY STAFF 

When staff are visiting patients in their homes with suspected or confirmed gastrointestinal 

illness, it is important that a high standard of hand hygiene is maintained and the appropriate 

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protective clothing worn. If hand washing facilities are unsuitable within the home staff should 

use alcohol hand gel/sanitizer, washing their hands at the earliest opportunity. 

ENVIRONMENTAL CLEANING 

Single use disposable plastic apron and gloves must be worn when carrying out general 

cleaning duties. 

Where environmental contamination occurs, see section on page E 6 of the guideline relating to 

cleaning of spillages of vomit /faeces. 

Domestic staff must clean the general ward environment thoroughly each day, using a solution 

of detergent and warm water A high level of general cleanliness must be maintained at all 

times, cleaning from unaffected to affected areas. In areas where there are affected patients the 

area/s (horizontal surfaces, floors, toilets and door handles) should be cleaned using a solution 

of detergent with a chlorine releasing agent e.g. Actichlor Plus. Dilution should be 1,000ppm 

(refer to container for guidance on dilution). 

The domestic should report to the nurse in charge each day at the start of their shift for any 

additional change to the cleaning regimens 

Patient care equipment should be cleaned by nursing staff using a solution of detergent and a 

chlorine releasing agent e.g. Actichlor Plus. Dilution should be 1,000ppm available chlorine 

(refer to container for guidance on dilution). 

At the conclusion of the outbreak the area should be terminally cleaned as per local protocol. 

CONCLUSION OF AN OUTBREAK 

The Infection Control Team, will determine when the outbreak is over. 

The nurse in charge will be informed and he/she will inform the following people: 

The Senior Manager for Nursing. 

The Clinician or General Practitioner on duty/call. 

Domestic Services. 

The Infection Control Team will inform all other relevant parties via e-mail that the outbreak 

has been declared over 

It is important to note that the ward must not be reopened until the above 

communications have taken place, and a full terminal clean has been carried out. The 

communications to the nurse in charge would normally take place via the Infection 

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Control Team, however at weekends and during public holidays it would be via the on-call 

Microbiologist (contactable via the relevant switchboard). 

The Infection Control Team may review the experience of all participants involved in the 

outbreak, to identify any particular difficulties/shortfalls encountered and make 

recommendations as required. 

The Infection Control Team will compile a summary report for the Infection Control 

Committee and a copy will be submitted to the Consultant in Public Health Medicine. The 

Infection Control Team will also complete a DATIX .incident form. 

OTHER PRACTICAL CONSIDERATIONS FOR CLINICAL AND INFECTION 

CONTROL TEAMS 

Once the closed ward has re-opened ward staff should: 

o Admit patients to clean bay areas first. 

o Be alert to the possibility of the outbreak reigniting and be ready to re-institute control 

measures. 

o Continue to provide additional cleaning advice to domestic staff. 

ICTs – should be alert to warnings of increases in Norovirus activity through the HPS weekly 

Monday Prevalence and NHS 24 excedence reports. Advise medical receiving teams when the 

Norovirus risk is high. 

Bed Management Liaison and Infection Control Teams: must work closely together to 

ensure optimal patient safety for all patients. Early communications and pre-planning of reopening 

should assist in reducing the impact of Norovirus outbreaks. 

PROTOCOL FOR STAFF WITH GASTROINTESTINAL ILLNESS 

Any member of staff displaying unexplained sudden onset gastrointestinal symptoms of either 

vomiting and/or diarrhoea, should refrain from duty until they have been asymptomatic for a 

period of a full 48hrs. 

If a member of staff becomes ill, whilst on duty, they should be sent home immediately. 

The nurse in charge should inform SALUS Occupational Health, who will in turn follow-up the 

staff member until they return to duty. 

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Staff suffering from diarrhoea may be asked, if possible, to provide a stool sample. This would 

normally be sent to the laboratory via the staff member's G.P., or their place of work via 

Occupational Health. 

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3. BIBLIOGRAPHY 



Section E1 








Chadwick, P. R., et al. (2000), The Management of Outbreaks of Gastro-enteritis due to 

Small Round Structured Viruses, Journal of Hospital Infection, 45 pp1-10. 

Guidance on the Investigation and Control of Outbreaks of Foodborne Disease in 

Scotland 2002, The Scottish Executive Health Department, Edinburgh. 

Guidelines for Cleaning, Disinfection and Sterilisation (2009), Section I, NHS Lanarkshire 

Control of Infection Manual. 

Guidelines for Hand Hygiene (2009), Section H, NHS Lanarkshire Control of Infection 

Manual. 

Guidelines for the Management of Healthcare Waste (2009), Section K, NHS Lanarkshire 

Control of Infection Manual. 

Infection Control and Patient Care (2009), Section C, NHS Lanarkshire Control of Infection 

Manual. 

Jenkins, L. (2004), The Prevention of Clostridium Difficilie Associated Diarrhoea in 

Hospital, Nursing Times Supplement, Vol 100, No.26. 

Kyne, Merry, et. al. (1999), Factors Associated with Prolonged Symptoms and Severe 

Disease due to Clostridium Difficile, Age and Ageing, 28, pp107-113. 

Management of In-Patients with Loose Stools (2005), Section E1, NHS Lanarkshire Control 

of Infection Manual. 

National Clostridium Difficilie Standards Group (2004), Report to the Department of 

Health, Journal of Hospital Infection, Vol 56, Supplement 1. 

National Guidelines on the management of outbreaks of Norovirus in healthcare settings 

(2003), Viral Gastro-enteritis Subcommittee of the scientific Advisory Committee of the 

National Disease Surveillance Centre. 

Norovirus Outbreak: Control measures & practical considerations for optimal patient 

safety and service continuation in hospitals, (2009). Health Protection Scotland 

Prevention of Bloodborne Virus, (2009), Section G, NHS Lanarkshire Control of Infection 

Manual. 

Yasmin, S. F. (2001), Clostridium difficile Associated Diarrhoea and Colitis, Mayo 

Foundation or Medical Education and Research, Vol 76 (7), pp725-730. 

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Section E1 






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Appendix 1







Section E1 






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Appendix 2 

SPECIMENS 

Faecal specimens should be collected from the symptomatic patients as early as possible; preferably not 

longer than 24 to 48 hrs after onset of symptoms. 

Use the correct sampling bottle or container for the type of specimen collected 

The specimen must be safely contained, and clearly labelled 

Specimens must be packaged to minimise the chance of breakage or leakage in the course of 

normal transport 

Document in the patient’s nursing/ medical notes what and when specimens have been taken 

REQUEST FORMS 

A request form should be sent with each specimen 

The correct Patient Label/ information (if available) should be attached to the request form. 

This assists the assessing of the request onto the laboratory computer system and the prevention 

of mis-labelling and/or mis-matching of samples 

All request forms must clearly state the name of the clinician requesting the investigation 

ALL REQUEST FORMS MUST CONTAIN THE FOLLOWING: 

o Patient Details: Name Address Date of Birth, Sex 

o Relevant clinical details including current, recent or proposed antibiotic therapy 

This is very important as it often dictates the method of investigation and the 

interpretation of subsequent results 

o Specimen details - clinical information need not be wordy, but should be 

focused 

o Investigation required 

If patient is part of an outbreak, advice should be sought from the Infection Control Team to ensure this 

information is documented on the request form. 

TRANSPORT OF SPECIMENS 

Specimens should be placed in a single transport bag and sealed to contain spillage and 

contamination







DAILY STOOL CHART INFECTION CONTROL SERVICE 

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Review Date Dec 2012 

NAME _____________________________ ONSET OF SYMPTOMS 

WARD _____________________________ DATE / / 

HOSPITAL _____________________________ TIME________________am/pm 

Amount Colour Consistency Skin Condition 

Sacrum/Buttocks 

Specimen Sent to 

Laboratory 

When a patient develops looses stools, implement enteric precautions and use this form to chart all bowel movements 

Appendix 3 

Signature







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Appendix 4 

MEMBERSHIP OF OUTBREAK CONTROL TEAM (OCT) 

The following list of staff members are representative of the core members and co-opted members of 

an outbreak control team, and would be convened for the local management of a serious outbreak of 

gastrointestinal illness. The list is not exhaustive, and other members may be co-opted as required. 

CORE MEMBERS 

Infection Control Doctor/Microbiologist 

Consultant in Public Health Medicine 

Medical Director/Deputy 

Infection Control Adviser/Nurse 

Consultant/Deputy in charge of patients 

Occupational Health Representative 

General/Service Manager/Deputy 

Senior Manager for Nursing/Deputy 

Ward Manager/Deputy 

Bed Manager 

Facilities/Hotel Services Manager 

Secretarial Support 

CO-OPTED MEMBERS AS APPROPRIATE 

Pharmacy Representative 

Environmental Health Officer 

Communications Manager 

Public Health Infection Control Adviser 

Procurement Representative 

Linen Room Supervisor 

Estates Manager 

Health Protection Scotland 

Accident and Emergency Consultant 

Food Standards Agency 

The Outbreak Control Team, if required, should be convened as soon as practical after an outbreak has 

been declared. 

The frequency of the meetings will be determined by the nature and extent of the outbreak, and the 

level of support required by the affected area. 

The manager of the affected area should provide secretarial support. Minutes of meetings should be 

produced and circulated to all members of the Outbreak Control Team and if deemed necessary 

members of the Executive Management Team. 

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Hospital Infection Incident Assessment (HIIA) Tool 

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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 

Minor 

Moderate 

Major 

Patients Services Public Health Public Anxiety٭ 

Only minor interventional 

support needed as a 

consequence of the incident. 

No mortality. 

Patients require moderate 

interventional support, but no 

mortality as a consequence of 

the incident. 

Life threatening illness or 

death as a consequence of 

the incident in one or more 

patients. 

No, or very short term closure of 

clinical area(s) with minor impact on 

any service. 

Short term closure(s) having moderate 

impact on some services, e.g. multiple 

wards closed or ITU closed. 

Significant disruption and impact on 

services, e.g. hospital closures for any 

period of time. 

No, or only minor 

implications for public health. 

Moderate implications, i.e. 

there is a moderate risk of 

only moderate impact 

infections to other persons. 

Significant implications for 

public health, i.e. there is a 

moderate or major risk of 

major infection to someone 

else 

No significant increased 

anxiety or concern 

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 in line with the HIIA Tool Colour 

Green 

Amber Red 

Appendix 5 

Increased concern and or 

anxiety anticipated. 

Alarm within at least some 

areas of the community 

anticipated 

Manage within the NHS Board. 

Report to SGHD. Engage with CPHM. Log on Report to SGHD. Engage with CPHM. 

Log SHORS if an outbreak . 

SHORS and report to HPS if an outbreak. Ask HPS 

Report to HPS٭٭ 

Inform CPHM 

for support if requireedr ٭٭ 

Log on SHORS if an outbreak 

Consider issuing press statement 

(prepare holding statement)٭٭٭ 

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 other 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. ٭٭٭As far as is practicable, patients and relatives should be informed of an incident prior to press statement release. All press 

statements should be shared with SGHD and HPS







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Outbreak Record Form (Gastroenteritis) 

Appendix 6 

CODE:…………………. 

Diarrhoea (colour coded in red) Vomiting (colour coded in green) Vomiting and Diarrhoea (colour coded in blue) 

PV =projectile vomiting, LAX =laxatives, V =vomiting, A =asymptomatic, NV =Norovirus, D + V =vomiting and diarrhoea, AB =antibiotics, CDT =C. diff toxin +ve, D =diarrhoea 

Ward / Area No of beds in Ward/ Area 

Date Reported Total no. of patients in area 

Time Reported Total no. of staff in area 

Date of first symptoms Total no. of persons involved in outbreak 

No Name Hosp 

No. 

DOB Staff/ 

Patient 

First 

Symptoms 

Date 

Reported 

Onset 

date 

Spec 

date 

Comment Room 

no 

Date and Symptoms







DAILY STOOL SPECIMEN FORM 

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Hospital: Ward: Code: 

No. Name D.O.B. P/S Date Specimen 

Sent 

Date Result 

Received 

Appendix 7 

Specimen Result







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Daily Checklist for Wards Closed due to an Outbreak of Gastroenteritis. 

Hospital_________________________ Ward____________________ ICT Informed Date: Date 

The ward is closed to admissions and transfers - until 48 hours after last new case and 48 hours after last diarrhoea/vomit. The closure time of the ward 

may be extended based on specific epidemiological data and at the request of the ICT. 

The ward (and side-room) doors are closed and there is an approved notice on the ward door advising visitors of necessary actions. 

All healthcare Workers (HCW) on the ward are: 

Aware of the status of the ward and how Norovirus/gastroenteritis is transmitted. 

Symptom free. If HCW is symptomatic they must remain of duty until 48 hours asymptomatic, they must also notify Occupational 

Health. 

Allocated – if possible – to care for either affected or non-affected areas of the ward – including agency and bank staff. 

All patients (and relatives) on the ward are aware of the Norovirus situation and have been given information leaflets on Norovirus/D&V and the need 

for hand hygiene, and safe handling of personal laundry. 

All patients with symptoms have been assessed today for symptom severity and assessed for signs of possible dehydration (Stool and Fluid Balance 

charts) 

Outbreak Record form has been updated – including any new cases, the symptoms patients are experiencing today and laboratory data. (Stool samples 

have been requested from all symptomatic patients). 

Patient Placement Assessment: A patient placement assessment and any advised/suggested moves have been made today. Patients should not leave the 

ward for other investigations/treatment unless this is clinically necessary, liaise with ICT before doing so. 

Personal Protective Equipment (PPE) – gloves, apron, surgical mask/visor (if risk of facial contamination with aerosols). 

There are sufficient supplies of PPE in the ward; 

used for single tasks and once removed hand washing is performed using liquid soap and warm water. 

used before contact with the patient or the patient’s immediate environment or before any dirty task. 

Hand Hygiene is being carried out with liquid soap and warm water – this can be followed by hand sanitiser. HCW must comply with NHSL Hand 

Hygiene policy. 

Patients are encouraged and given assistance to perform hand hygiene before meals and after attending the toilet. 

Management of waste: For the duration of the outbreak all waste should be disposed of as clinical waste (orange stream). Domestic waste bins should 

not be used during outbreaks. 

Environment: The environment is visibly clean – including curtains – there is increased cleaning which includes decontamination of frequently touched 

surfaces with detergent and 1000ppm chlorine releasing agent. [Cleaning schedules up to date]. 

Environment: There are no exposed foods in the ward area – even if unexposed all fruit should be washed before eating. 

Appendix 8







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Equipment: Where possible single patient equipment is used and communal patient equipment avoided. All reusable equipment is decontaminated after 

use. There are sufficient other sundries on the ward to enable the control measures to be implemented. 

Linen: Whilst the ward remains closed, categorise all discarded linen as ‘foul/infected’ 

Spillages: All faecal and vomit spillages are decontaminated by staff wearing appropriate PPE. The spillage is removed with paper towels, and then the 

area is decontaminated with 1000ppm of a chlorine releasing agent. All waste arising is discarded as clinical waste. PPE is then removed and hands 

washed with liquid soap and warm water. 

Advice and Guidance: HCWs have access to, and follow NHSL guidance on: 

The decontamination of body fluid spills, equipment, soft furnishings (Section I and ward Cleaning Schedules) 

If uniform becomes contaminated HCW must complete a DATIX and send uniform to laundry for cleaning. 

Today the ICT has made an assessment of the outbreak and the continuing need for ward closure. The earliest possible date for reopening has been 

communicated to the clinical team, to bed management staff and those listed in the Outbreak policy. 

In preparation for reopening – empty beds have been cleaned and left unmade. Consider pre-booking a terminal clean. 

Before reopening – a terminal clean has been performed following ICT recommendation and following the hospital procedure. 

It is the Senior Charge Nurse/Deputy’s responsibility to ensure that all infection control measures are adhered to and that a DATIXhas been completed 

at the end of the outbreak. 

Issues Reason Action taken Signature Date







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PATIENTS WITH VOMITING AND DIARRHOEA 

Ward: _____________________________ Date: _____________________________ 

Appendix 9 

Nursing staff to complete 

Please record all patients with projectile vomiting and/or 3 or more episodes of unexplained diarrhoea/loose stools 

A new chart should be started each morning at 9 am by the day staff. The Infection Control Nurses will retain the previous days chart 

Every episode of vomiting and diarrhoea should be recorded with a tick (√ ) 

Patient’s Name Date Sample Obtained Vomiting Diarrhoea







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Protocol For Cohort Isolation During Suspected or Confirmed Outbreaks Of Norovirus 

Appendix 10 

Cohort isolation has long been recognised as a means of assisting with controlling the spread of infection within 

ward environments, and if practiced well can result in the avoidance of restrictions being placed on the whole of 

the ward.. It is a practice that is often adopted in the absence of available side rooms for patients displaying 

similar signs and symptoms. Prior to cohort nursing, Bed managers should risk assess the availability of single 

rooms in other clinical areas, this should always be done in conjunction with the ICT. Generally cohort isolation 

takes place within 4 – 6 bedded bays 

It is imperative that for cohort isolation to be successful in containing the infection, the following points must be 

adhered to: - 

Where possible cohort patients must be cared for by designated staff especially when there is a high 

incidence of vomiting. Bank/Agency staff must not be involved in caring for patients in cohort isolation. 

The ICT must be contacted if compliance with the above cannot be achieved 

For effective isolation the door to the room must be kept closed at all times to provide physical separation 

from other patients 

The rooms used for cohort isolation must have a designated toilet and hand washing facilities 

Personal Protective Equipment (PPE), where possible should be sited outside the room 

Staff caring for patients must practice the highest standard in relation to the use of PPE and hand hygiene 

(level two hand wash should be performed at all times as per Section H, CIM 

Linen should be treated as foul/infected as per Section D, CIM 

Waste should be disposed off in the clinical waste stream as per Section K, CIM 

There should be clear signage placed on the door advising all visitors to the area to speak to the nurse in 

charge before entering the area 

The room must be cleaned on a daily basis following the guidance within Section E1, CIM point 1.19 

Environmental Cleaning 

Patients must remain cohorted in the same area until at least 48hrs after the last episode of vomiting and/or 

loose stools. There should be no patient movement in or out of the room until the restrictions have been 

lifted by the Infection Control Team (ICT). The exception to this would be if the patient was being 

discharged to their own home, or if the patient was requiring an urgent medical/surgical 

investigation/intervention. The ICT must always be fully consulted prior to any decision being made. 

Meals and medicine rounds should be carried out last in cohort rooms 

It is important for staff to routinely provide affected/unaffected patients and visitors with an 

explanation of their infection, isolation procedures and treatment, especially patients who are 

asymptomatic, but potentially incubating the infection 

The ICT will review the situation on a daily basis, any breach of the above guidelines, or signs that the infection 

has not been successfully contained i.e. other patients or staff displaying similar signs and symptoms, may result 

in restrictions being applied to the whole ward. A full risk assessment would be undertaken in line with the 

Infection Control Doctor and Senior Management before any decision was made.







NOROVIRUS INFECTION CONTROL 

STAFF INFORMATION 

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Appendix 11 

NOROVIRUS – AN OVERVIEW 

Noroviruses (NV), previously known as small round structured viruses (SRSV’s) and Norwalk like viruses 

(NLV’s) are the most common cause of outbreaks of gastro-enteritis in hospitals, schools, nursing/residential 

homes etc. These viruses can be highly infectious causing high attack rates among patients and staff within the 

hospital setting. Attack rates can reach as high as 50%-70% in patients and staff. 

Gastro-enteritis caused by Norovirus infection produces a self-limiting, mild to moderate disease with clinical 

symptoms of nausea, vomiting (often projectile), diarrhoea, abdominal pain, myalgia, headache, malaise, low 

grade fever or a combination of these symptoms which can last 12-72 hours. The elderly and patients with preexisting 

chronic medical conditions may develop more serious symptoms. Treatment in most cases is 

replacement fluids. 

IDENTIFICATION 

The virus may be identified in stool or vomit specimens, particularly if the specimen is obtained at the onset of 

symptoms. 

RESERVOIR 

Humans are the only known reservoir. 

ROUTE OF TRANSMISSION 

Probably by the faecal – oral route, although indirect transmission from environmental contamination and via 

aerosol has been suggested to explain the rapid spread in hospital settings. Food may also be a vehicle for 

transmission of infection. 

CHARACTERISTICS 

A rapid onset of diarrhoea and/or vomiting is commonly seen with a rapidly rising attack rate in both staff and 

patients alike. 

INCUBATION PERIOD 

Usually 12-48 hours. 

PERIOD OF COMMUNICABILITY 

During the acute stage of the disease, and up to 48 hours after diarrhoea/vomiting stops. 

SUSCEPTIBILITY 

Susceptibility is widespread and short-term immunity lasting up to 14 weeks has been reported.







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TYPING 

Typing of strains is not routinely carried out; therefore it is not possible to confirm that individual outbreaks are 

linked. 

RESTRICTION ON STAFF MOVEMENT, NURSING (INCLUDING BANK/AGENCY/STUDENT) 

AND DOMESTIC REQUIRES THAT: 

Essential services such as portering, medical etc would not normally be restricted. 

Staff with symptoms that fulfill the case definition must refrain from work as advised by Occupational 

Health and Safety Services and as directed by the Infection Control Team. 

For symptoms of gastro-enteritis, affected staff must refrain from duty for 48 hours, following cessation of 

symptoms. 

Staff working within the affected area MUST NOT be deployed to any other area unless out with the 

affected area for 48 hours or more without developing symptoms. 

Staff deployed to the restricted area WILL REMAIN deployed in that area for the duration of the outbreak. 

Other disciplines that provide direct patient care in the affected area would normally be restricted, such as 

physiotherapy, to ensure these essential services can provide healthcare in other areas. 

VISITORS TO THE AFFECTED AREA: 

Would not normally be restricted, but the numbers should be kept to a minimum. The nurse in charge should 

discourage the elderly, very young and immunocompromised. 

A notice must be placed on the entrance door informing of the outbreak, referring visitors to the Nurse in 

charge. 

Guidance must be given to visitors by the Nurse in charge on the prevention of infection such as hand 

washing (written guidance available). 

Visitors with symptoms must not visit unless 48 hours symptom free. 

ROUTINE MAINTENANCE WORK MUST NOT BE CARRIED OUT DURING AN OUTBREAK 

OTHER RESTRICTIONS MAY BE IMPOSED AT THE DISCRETION OF THE INFECTION 

CONTROL TEAM







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APPENDIX 12 

GASTROENTERITIS OUTBREAK IN THE CARE HOME SETTING INFECTION CONTROL 

ADVICE 

ESTABLISHMENT_______________________________________________________________ 

Record: 

Maintain Outbreak Record Form (ORF). 

Mark only the new cases. – Recurrence of symptoms should be marked in the comments section. 

Symptoms: 

- Loose stools/diarrhoea 

Frequency (?diarrhoea i.e., ≥ 3 loose stools in 24hrs 

Colour / mucous / blood 

Consistency 

- Vomiting 

- Abdominal pain 

- Fever 

Accommodation: 

Single room (preferably with toilet + W/H basin. 

Cohort nurse if necessary and appropriate 

(For shared rooms where only one person is symptomatic, the asymptomatic person can only be moved to a 

single room in the vicinity, otherwise they should remain in the shared room). 

Toilets: 

Toilet allocated for symptomatic persons use only. 

If commode necessary - allocate one to each symptomatic person or disinfect between use by different 

persons. 

Personal Protective Equipment: 

For contact with excreta, vomit or contaminated item wear disposable plastic apron and disposable 

latex/vinyl gloves and change between patients. 

Handwashing: 

Use liquid soap to wash and paper towels to dry: 

- after contact with resident and immediate environment 

- after removing gloves; 

- after contact with faeces, vomit or contaminated items. 

Instruct and assist residents where possible 

Pay close attention to confused/wanderers 

Laundry: 

As per CIM: 

Red water soluble bags 

Cool pre-wash







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65 o C for 10 mins or 71 o C for 3 mins. 

No hand sluicing of fouled items. 

Equipment: 

No shared equipment - if sharing necessary: disinfect between each resident. (see Control of Infection 

Manual [CIM]) 

Environmental cleaning: 

Clean up spills/contamination as soon as possible (see CIM) 

Maintain good domestic cleaning (increased toilet cleaning frequency may be required) 

Clinical Waste: 

Dispose of protective clothing, incontinence pads etc as clinical waste. 

Stool Specimens: 

Send stool specimens from all affected as soon as possible 

Mark specimen request form "outbreak" and request “virology testing” 

Staff: 

Stop if possible or limit staff movement between affected and non-infected areas of establishment. 

Staff from the infected area should refrain from working in other healthcare establishments for the duration 

of the outbreak. 

Avoid using agency staff in affected areas if possible, if used, ensure that agency is notified of outbreak. 

Symptomatic staff must stay off work until 48 hours symptom free. 

Food Samples: 

Retain all food samples until further notice 

Visitors: 

Visitors should be informed of the outbreak and advised that should they wish to visit they should restrict this 

to their relative only and avoid mixing with other residents/ visitors. 

Admissions 

During the outbreak the establishment will be closed to admissions. 

Transfers: 

Has there been, or is there any intended transfer of residents to another residential establishment or hospital? 

If so, 

- record details of date, time and location. 

- inform the receiving unit of the outbreak. 

Please ensure that this information is given to all staff 

Advice given to:…………………………………………. Date…./…./….. 

Advice given by:………………………………………….. Date…../…../….. 

For further advice contact Lanarkshire NHS Board, Health Protection Team (01698 858232) 

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Management of In-patients with Loose Stools ... - NHS Lanarkshire

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