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Preparation is key to containment

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Wendy Grey, RGN, Dip ICN; Stephanie Stewart, RGN, Dip ICN.

Both authors are Infection Control Nurses.

A significant increase in the incidence of infections caused by viral gastroenteritis, such as that caused by the Norwalk virus, was reported by the Public Health Laboratory Service (2002) for the UK in the past year.

A significant increase in the incidence of infections caused by viral gastroenteritis, such as that caused by the Norwalk virus, was reported by the Public Health Laboratory Service (2002) for the UK in the past year.

As infection control nurses, we undertook a review of outbreak procedures implemented during previous outbreaks at East Somerset NHS Trust, which revealed no uniformity in the way ward closures due to infection had been handled.

Poor communication between staff often resulted in conflicting information being provided to colleagues, patients and visitors. Handling infection control issues in the absence of infection control nurses was haphazard, and the records made by staff were inadequate, making retrospective review difficult. Data collection by ward staff was often insufficient. Makeshift hand-written signs were displayed on walls and doors. It was felt that these did not convey concise information and were often ignored or not noticed by people entering closed areas.

Conversations with infection control nurses from St James's University Hospital, Leeds, Calderdale and Huddersfield NHS Trust and Northumbria Health Care NHS Trust, led us to conclude that the problem was not uncommon and a range of methods had been used to improve poor communication.

We felt we needed to develop a new tool to tackle the issue in our own trust. Outbreak kits are common in other trusts, so we undertook a review of these, as well as the literature, through the Infection Control Nurses' Association discussion board to find the best evidence to help us develop our own outbreak kit.

Our aims included the need to standardise information to ensure that ward closures caused by infection outbreaks were dealt with consistently and that staff had access to a step-by-step guide to the process required to contain an outbreak and minimise the risk of further transmission. As part of the process, we updated the isolation signs and outbreak posters, making these highly visible and easy to understand by all those who might need to have access to the isolation room or area.

Kit contents
An information sheet - Detailed protocols and procedures are laid down in an information sheet given to staff in an affected area. This covers admissions, transfers and discharges to help restrict the spread of an outbreak.

Isolation or cohort nursing of symptomatic patients is also explained as part of the necessary control measures (Chadwick et al, 2000). Guidelines on the appropriate collection and examination of specimens for electron microscopy are included.

Increased environmental cleaning and hand hygiene is tackled by setting out guidelines for ward cleaning staff, to ensure they undertake the correct level of decontamination in key areas (Cheesbrough et al, 1997).

Advice leaflets - These are supplied to all affected areas during an outbreak to provide basic guidance to visitors, relatives and patients. They help ensure people's concordance during an outbreak. The leaflets advise on visiting restrictions, the spread of the virus, laundry issues, and signs and symptoms of viral gastroenteritis.

Records sheets - Outbreak record sheets are also included in the kits. These help keep track of the spread of an outbreak and are used to record the symptoms of those affected. The data have been invaluable to the infection control team, enabling us to track the progress of an outbreak and assisting us with retrospective report writing.

Posters - Laminated posters were produced on luminous paper, providing staff with a highly visible form of notifying people about current outbreak areas. Entrances to affected clinical areas display the 'Ward closed' sign as a visual prompt.

Additional information - Posters explaining the correct use of alcohol-gel points set up in public areas are also included in the outbreak kits. These aim to increase concordance by staff, patients and visitors throughout the hospital by prompting them to use appropriate hand-hygiene measures (Larson et al, 1997).

Advice on the correct disposal and storage of contaminated linen was also deemed relevant and was added to the kits after an evaluation of their initial use.

Siting and use of kits - Kits were distributed to all clinical areas at the acute site and staff trained to use them, to ensure that everyone was aware of when and how they should be used.

As an infection control session is part of the trust's induction programme, we opted to include training on the use of outbreak kits within this. Ad hoc training briefings also took place on the wards two weeks before the kits were first introduced.

Kit evaluation
The first major outbreak of Norwalk virus in the acute general hospital occurred two weeks after the kits were introduced. Use of the kits enabled quicker dissemination of general and specific information to staff, patients and visitors, and the feedback was positive.

Infection control containment measures were instigated rapidly in several wards simultaneously, enabling infection control nurses to devise a proactive action plan to tackle the outbreak early on.

Use of the kit ensured continuity of advice and informed staff which areas were affected as quickly as possible. Members of the public reported that the proactive method of delivering information went a long way to allaying their fears.

Negative points arising from the evaluation included difficulty in getting staff to complete the record sheets consistently. Ongoing training and experience gained from subsequent outbreaks have, however, led to improvements in this area.

Overall, introducing the outbreak kits has been a very successful undertaking, giving the trust an invaluable tool in facilitating communication between the infection control team and ward staff.

Chadwick, P.R., Beards, G., Brown D. et al. (2000)Management of hospital outbreaks of gastroenteritis due to small round structured viruses. Journal of Hospital Infection 45: 1, 1-10.

Cheesbrough, J.S., Barkess-Jones, L., Brown, D.W. (1997)Possible prolonged environmental survival of small round structured viruses. Journal of Hospital Infection 35: 4, 325-326.

Larson, E.L., Bryan, J.L., Adler, L.M., Blane, C. (1997)A multifaceted approach to changing handwashing behavior. American Journal of Infection Control 25: 1, 3-10.

Public Health Laboratory Service. (2002)Norovirus (Norwalk-like virus) increase in 2002. CDR Weekly 12, 51.

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