Norovirus

Evonne CurranNurse Consultant

Health Protection Scotland

In this presentation

• Norovirus GI infection• Why it causes us problems• Results of a survey of norovirus

experience 2009/10• Plans for 2010/11• Plans for after 2011

Why is norovirus such a problem in hospitals?

Immunity short lasting

50% attack rate

Low infectious

Dose (100vp)

Airborne dissemination

SICPs not enough

Odd presentations – is it a case?

Voluminous diarrhoea &

vomiting

No prodromeInfectious before

symptoms

invisible

environmental

contamination

Martin et al. Eurosurveillance 2004 Age sex distribution norovirus

Schulzke, et al GUT 2008

‘The diarrhoea in norovirus infection is driven by both a leak flux and a

secretory component.’

It’s not always mild and there is an associated mortality

•Nothing can be done•Nothing works•We just go through rituals•Should not bother

•No one comes into hospital to get an infection•By being prepared we can reduce the impact of norovirus

Reduction in outbreaks on cruises• Changing their ways of working

– Surveillance (real time data)– Look for cases– Action when cases

•Serve buffet, laundry services, isolation, cabin with window, hand hygiene facilities, check you are doing what you are supposed to be doing, remind people what to do, non buffet but restaurant.

Firepro

of

Fire fightin

g

Norovirus season evaluation 2009/10• How was it for you?

Not so bad

A pain: the worst ever

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Key comments

Lots of small fires starting at onceWhen it came it came quickly

Lots of relapses

NB The ward reopening is not the point when its no longer a problem it’s the point when its manageable

The perfect norovirus storm

• Increased referrals by out of hours GPs

• Fewer coping services• Fewer experts to say ‘no’• Weekends – no full ICN service

What we do

• Let everyone know its started 5/11

• Let key HCWs know its started 6/11

• Keep everyone updated once its started 8/11

Good Practice Points

• Run workshops (doctors)• The CE puts a letter out• Note in the pay slips • Point prevalence data to bed

management• Whole hospital on alert once it starts• Attend daily bed management

Do you remind staff to

• Check referring GP if diarrhoea or diarrhoea in care home 4/11

• Provide GPs with advice managing noro in the community 6/11

• Require docs to ask about diarrhoea when taking a history 6/11

• Avoid unnecessary moves 11/0

Do you have • Policy to avoid unnecessary

admissions 3/11• Advice that patients with DV to

isolation 11/0• Advice to minimise CI in home 8/11• A&E algorithm 5/5• A&E procedure when Noro + MI 5/11• Contingency plans 3/11

Do you think that recognising patients with possible norovirus symptoms as an infection risk is a problem in your hospitals ?

• Yes 8/11• Failure to recognise risk

Biggest problem when risk recognised

• Insufficient isolation facilities• Competing priorities (A&E

targets)• Isolation requirement not passed

on

Recognition of outbreak• Early 9/11 established 2/11 • Transfer pre closure 3/11 never• Speed of closure – excellent

‘except at weekends’

• Ward staff are quick sometimes started precautions before I get there

‘How leaky is your bucket?’

Are you able to continuously apply norovirus guidelines?

• Yes 7 / 11

Other Key issues

• No data on exactly when each outbreak occurs

• Visitors

Lots of good testing ideas

• Quarantined not closed

• Management of paired wards

• Norovirus diaries

Lets plug the holes in the bucket!

• Contingency planning• Start date• A&E algorithm• Admission avoidance at weekends• Nursing home admission avoidance• Visitors• RCA

Contingency planning

Pre-start of season: • There is a plan for a norovirus outbreak includes

who does what!• A contingency plan to reduce norovirus impact

and the likelihood of norovirus outbreaks getting out of control (includes comms and single ward option)

• Who at board level CPHM will help• Agreed norovirus activity locally:

– Green: single wards in single hospitals– Amber: more than single wards in single

hospitals – no pressure on routine services– Red: more than single wards closed – routine

services being stopped– Black: One or more hospital closed due to

multiple ward closures

Season has started nationally:• Confirm Norovirus contingency plan still valid• Any changes needed to noro email groups • Visit A&E / bed management – remind of algorithm

inform of national situation• Remind of how noro presents • Remind what to ask / what to do• Powerpoint for all new staff since last season• Collective ID of the weakest links and mitigate• Confirm / remind all wards of norovirus (e)folder of

what to do• Email who to contact for noro – at weekends or after 5• Get board public comms ready – Get top level co-

operation• Liaise with board re any N home outbreaks• Weekend cover of ICN?

Ward X and Y are closed to

due to norovirus.

Visitor restrictions apply

Season has started locally:

• Tell everyone – including the media• Tell the visitors at the front door• All meet and greet• Daily meetings with bed-management• Daily sit rep with local norovirus

assessment• Id how did the index case cause the

outbreak – feedback• Assess all outbreaks for lessons learned• Share lessons learned locally and with

HPS

Season over• Season debrief management and

ICT– What worked well? – What could have worked better?– What will make it work better

next time?– Share findings – Share with HPS

If we fail to prepare, we prepare to fail

B Franklin

Norovirus will continue to be

• A severe winter challenge to NHSScotland

• Better preparation and execution of preparation plans will reduce its impact on ourselves and our services but more importantly….