Full Title of This Presentation or Section

Full Title of This Presentation or Section

MISSION Improve the quality of healthcare in Pennsylvania by collecting and Norovirus Prevention and Control Training analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. VISION

Safe healthcare for all patients 2018 Pennsylvania Patient Safety Authority Objectives Assess the effect of factors that increase the potential for a norovirus outbreak Identify key components of a standardized multidisciplinary norovirus prevention and control program Translate evidence-based interventions into actionable facility practices that impact norovirus 2018 Pennsylvania Patient Safety Authority

2 Viral Risk Factors Low infectious dose10 viral particles 50% of inoculated individuals become symptomatic Intestinal and gastric damage High viral load x 48 hours Viral shedding 2-3 weeks Limited short-term immunity 2018 Pennsylvania Patient Safety Authority 3

Host Risk Factors Communal living Shared toileting facilities Social dining and activities Incontinence hygiene Clinical features Acute onset nausea, vomiting Watery, nonbloody diarrhea Abdominal pain, low-grade fever Onset 12-48 hrs; resolves in 24-72 hrs Prolonged recovery, complications 2018 Pennsylvania Patient Safety Authority 4

Host Risk Factors Contaminated food sources Hands of ill food handlers Shellfish or water contaminated with raw sewage Oral contact after exposure to Contaminated body fluids or skin surfaces Environmental surfaces contaminated with fecal material Exposure to aerosolized vomitus Virus is stable on hands for several hours Secondary person-to-person transmission 2018 Pennsylvania Patient Safety Authority 5

Transmission Direct transfer Viral shedding from a colonized or infected person to another person, bed surface, linens, faucets, food, etc., via contaminated hands or even gloves touching the surface Indirect transfer Contact with contaminated surface and transfer to a noncolonized or uninfected patient Contact with the surface by another person, followed by oral inoculation 2018 Pennsylvania Patient Safety Authority

6 Environmental Risk Factors Stableresists heat and freezing Remains virulent after prolonged periods of time on surfaces Resistant to many disinfectants Transiently colonizes healthcare workers hands Secondary transfer to as many as seven additional surfaces 2018 Pennsylvania Patient Safety Authority 7 Education

Staff, patients/residents, visitors Viral, host, environmental factors Norovirus detection, transmission, symptoms, prevention Annual, new cases, outbreak In-services, notices, handouts, posters Review, monitor, reinforce adherence 2018 Pennsylvania Patient Safety Authority 8 Surveillance System Enable rapid clinical confirmation of potential cases Clear case definition

Line listing logs Systems to find, monitor, and record case information Facility-specific norovirus baseline Facility-specific norovirus rate by unit 2018 Pennsylvania Patient Safety Authority 9 Line Listing 2018 Pennsylvania Patient Safety Authority 10

Resources Hand hygiene supplies Enhanced environmental cleaning Appropriate disinfectants Personal protective equipment (PPE) for isolation Single-use, dedicated patient-care equipment Commode, rectal thermometers Toileting supplies Precaution signs and education materials 2018 Pennsylvania Patient Safety Authority 11

Communication Plan Rapid dissemination of information Location and extent of the infection Control measures Requirements for documentation Notification of ongoing cases 2018 Pennsylvania Patient Safety Authority 12 Communication Plan (cont.) Designate responsibility Patient/resident care areas

Patients/residents, families Providers, the medical director Facility leadership, corporate bodies Local health department 2018 Pennsylvania Patient Safety Authority 13 StaffingEmployee Health Exclude ill staff from work for 48 hours Exclude nonessential staff, students, and volunteers from outbreak areas Establish protocols for staff cohorting

Cohorts: symptomatic, exposed but asymptomatic, or unexposed Do not move between patient cohorts 2018 Pennsylvania Patient Safety Authority 14 Rapid Response Plan Evidence-based interventions: Early detection of cases Contact precautions application Strict hand hygiene Enhanced environmental cleaning Linen handling

Enhanced precautions 2018 Pennsylvania Patient Safety Authority 15 Early Detection Stool specimen Kaplan criteria Vomiting in more than half of symptomatic cases The mean or median duration of illness ranges between 12 and 60 hours The mean or median incubation period ranges between 24 and 48 hours

No bacterial pathogen found in stool cultures 2018 Pennsylvania Patient Safety Authority 16 Contact Precautions Private rooms/cohorts Symptomatic, exposed but asymptomatic, and unexposed Separate toilet/commode Segregate residents/patient/staff from affected wards Continue for 48 hrs after resolution of symptoms PPE for cleaning/care of ill residents

2018 Pennsylvania Patient Safety Authority 17 Hand Hygiene Effective hand hygiene program Actively promote adherence to 2002 Centers for Disease Control and Prevention (CDC) guideline Soap and water for resident care/contact with norovirus Alcohol efficacy unresolved Human challenge study2003 Hand washing with an antibacterial soap for at least 1 minute Rinsing for 20 seconds/drying with a disposable paper towel

2018 Pennsylvania Patient Safety Authority 18 Environmental Cleaning Clean and disinfect patient care areas at least twice daily Clean and disinfect frequently touched surfaces at least three times daily EPA-registered product list Chlorine bleach-to-water ratio of 1:50 Clean lesser-contaminated surfaces first

Discard unused disposables 2018 Pennsylvania Patient Safety Authority 19 Linen Handling Virus dispersed when agitating soiled linens PPE use minimizes the likelihood of personal contamination Change privacy curtain when visibly soiled and upon patient discharge Launder unused linens remaining in patient rooms before use on another patient Steam clean upholstery or discard

Double bagging, incineration, and laundering modifications are not recommended 2018 Pennsylvania Patient Safety Authority 20 Enhanced Precautions Restrict movement of symptomatic and recovering patients Suspend group activities (e.g., dining events) Close wards to new admissions or transfers Visitors: Screening visitors for symptoms consistent with norovirus infection is encouraged Restrict nonessential visitors from affected areas during outbreaks of

norovirus gastroenteritis 2018 Pennsylvania Patient Safety Authority 21 The Patient Safety Authority Toolkit Controlling the Annual Threat of Norovirus Gastroenteritis Outbreaks (Advisory article) Designing a Norovirus Prevention and Rapid Response Program: An Evidence-Based Approach (recorded webinar) Norovirus Preparedness Checklist Acute Gastroenteritis Outbreaks Case Log Norovirus Preparedness: Outcome and Process Measures Worksheet YouTube video podcast: Norovirus Preparedness and Controlling the Annual Threat of a

Norovirus Outbreak Stop the Spread of Norovirus Posters for Clinicians and Patients Patient Safety Topics: http://patientsafety.pa.gov/pst/Pages/Norovirus/hm.aspx 2018 Pennsylvania Patient Safety Authority 22 Resources Centers for Disease Control and Prevention

Updated Norovirus Outbreak Management and Disease Prevention [online]. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6003a1.htm?s_cid=rr6003a1_w Guideline for Hand Hygiene in Health-Care Settings. MMWR Recomm Rep. 2002 Oct 25;51(RR16):1-45, quiz CE1-4. https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf Weber DJ, Rutala WA, Miller MB, Huslage K, Sickbert-Bennett E. Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control. 2010 Jun;38(5 Suppl1):S25-33.

Barker J, Vipond IB, Bloomfield SF. Effect of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces. J Hosp Infect. 2004 Sep;58(1):42-9. 2018 Pennsylvania Patient Safety Authority 23 Questions? 2018 Pennsylvania Patient Safety Authority 24

Thank you for your kind attention! 2018 Pennsylvania Patient Safety Authority

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