document type: protocol reference 0653 13 review date: 23

Collated by Clinical Effectiveness Outbreaks of Viral Diarrhoea and / or Vomiting, the Management ofVersion 13 (April 2021) of 36

Index

1.0 Introduction 3

1.1 MIU/Clinic Area 3

2.0 Criteria for Suspecting an Outbreak 3

3.0 Actions of key personnel in the event of a suspected/confirmed outbreak 4

3.1 Nurse in Charge 43.2 Domestic Services 53.3 Infection Prevention and Control Department 53.4 Director of Infection Prevention and Control (DIPC) 6

4.0 Control Measures for Ward Closure 64.1 Admissions 64.2 Movement of Staff 74.3 Discharges to other wards/departments, nursing & residential

homes or patients own home 74.4 Porters 74.5 Transfer of patients to Departments for Procedures/Appointment 74.6 Support services 84.7 Visitors 84.8 Microbiology Laboratory and Norovirus Testing Requests 8

5.0 Infection Control Precautions 95.1 Hand Hygiene 95.2 Protective Clothing 95.3 Linen 9

6.0 Control Measures for Bay Closure 106.1 Admissions 106.2 Discharges to other wards/departments, nursing &residential

homes or patients own home 10 6.3 Porters 106.4 Transfer of patients to Departments for Procedures/Appointments. 106.5 Support services 106.6 Protective Clothing/Measures 116.7 Patients 116.8 Visitors 11

7.0 Staff Sickness 11

8.0 Criteria for Reopening a Ward 11

Document Type: ProtocolReferenceNumber : 0653

VersionNumber: 13

NextReview Date: 23 April 2024

Title: Outbreaks of Viral Diarrhoea And/Or Vomiting, ManagementOf

Document Author: Infection Control

Applicability: All staff


9.0 Responsibility of Key Staff during Terminal Cleaning 12

9.1 Nursing Staff 129.2 Facilities Manager / Supervisor 129.3 Facilities Management 129.4 Estates Department 129.5 Stores 12

APPENDICES

Appendix 1 Norovirus Escalation Plan 13Appendix 2 Admission Checklist/Risk Assessment Algorithm 19Appendix 3 Ward Record Sheets 20Appendix 4 Outbreak Control Measures 25Appendix 5 Checklist For Admission To Closed Ward 28Appendix 6 Letter To Patient/Relative/Cover When Admitted To Closed

Ward 29Appendix 7 Temporary Worker 30Appendix 8 Social Services/District Nursing 31Appendix 9 Visitor Risk Assessment Algorithm 32Appendix 10 Sign For Bay Closure 33Appendix 11 Visitors Information Leaflet – Linked to 22086 34Appendix 12 Deep Cleaning Procedure 35Appendix 13 Guidelines for the Terminal Cleaning of a Ward Following an

Outbreak Infection 36

Document Control

Mental Capacity Act 2005 and Infection Control Statement

37

39

Quality Impact Assessment 40

http://www.torbayandsouthdevon.nhs.uk/uploads/22086.pdf


1.0 Introduction

Outbreaks of viral diarrhoea and/or vomiting usually occur within the winter months. In mostcases the cause is Norovirus but can be other small round structured viruses such asrotavirus.

The epidemiology of Norovirus changes over time and geography. The emergence of newstrains will continue to challenge us as populations at risk, including employees of affectedorganisations continuously renew. Meeting these challenges will require robust surveillanceof outbreaks and sentinel surveillance of Norovirus activity in neighbouring organisationsand the wider community. (See Norovirus escalation plan appendix 1).

An outbreak can lead to ward bay/s and ward/s closures causing disruption to hospital activity. Thevirus affects patients, staff and relatives. When an outbreak is suspected many patients mayalready have been exposed therefore control measures must be centred on containment to onearea preventing spread to other areas.

If there is a case of diarrhoea and vomiting in a bay that bay will be closed and the ward will remainopen. However, should other bays become affected and staff symptomatic then the ward will beclosed.

One of the measures to prevent spread to ward areas is to complete the risk assessment fordiarrhoea and/or vomiting to all new admissions (appendix 2). Any patient suspected of having viraldiarrhoea and/or vomiting must be admitted to a side room immediately.

1.1 Minor Injury Units/Clinic Areas/AMUOutbreaks are unlikely to occur in these areas, but if an attending patient has diarrhoeaand/or vomiting contact Infection Prevention and Control Department (IP&CD).

1.2 All staff working in the community who may need to attend patients in residential/care homesthat have an outbreak of diarrhoea/vomiting should make essential visits only and thosevisits should be at the end of community staffs daily visits. If in doubt, please contact theInfection Prevention and Control Department

2.0 Criteria for Suspecting an Outbreak

2.1 An outbreak of diarrhoea and/or vomiting can usually be defined by 2 or more patients withunexplained diarrhoea and/or vomiting. Staff and patients are affected and in most casesthere is projectile vomiting and diarrhoea, although in some cases there is only diarrhoea orvomiting. Other clinical symptoms are myalgia, slight pyrexia, headache and abdominalcramps.

.2.2 When patients present with these symptoms the IPCD must be informed as soon as

possible. The IPCD are available 08.30 – 17.00 Monday to Friday on 01803 655757. TheConsultant Microbiologist is available at all other times via switchboard 01803 614567.


3.0 Actions of key personnel in the event of a suspected/confirmed outbreak.

3.1 Nurse in Charge.

When the Nurse in Charge suspects an outbreak the following information must be collected andrecorded on the ward record sheet (appendix 3). Occasionally there can be underlyingconditions that can lead to diarrhoea AND vomiting however if there is any doubt it isadvisable to err on the side of caution and isolate the patient whilst the patient is fullyevaluated.

· Name· Hospital Number· NHS Number· Date of Birth· Diagnosis· Date of Admission, and from where i.e. Residential Home· Drug History· Food History· Date/time symptoms started· Patients bed location.· Normal bowel action

Other information that is required is the numbers of patients/staff relatives with symptoms.

The nurse in charge must then inform the Matron and IPCD as soon as possible between 08.30 –17.00 Monday to Friday. The Consultant Microbiologist is available at all other times viaswitchboard, however, between the hours of 10pm and 8am, the Bed Managers will make sensibledecisions (e.g. move symptomatic patients into side rooms / get ad hoc cleaning teams involved /close bed spaces overnight to new admissions), but the decision formally to close the bay should beleft until 8am when the situation must be discussed with the microbiologist on call who would be theonly ones that could ‘formally’ close a bay.

The Director of Infection Prevention and Control (DIPC)/Consultant Microbiologist or IPCD ONLYwill then make a decision on whether to close the bay/ward.

If a decision is made by Infection Control to close the bay/ward:

· The IPCD will communicate with the Control Meeting and the ward daily.

· The Nurse in Charge must complete the Outbreak Control Measures sheet and ensurechecks on the PPE use and hand hygiene are monitored. Appendix 4.

· The Matron in Charge of the outbreak area must collect and supply the following informationby 10am to the daily control meeting:

· New cases among patients· New cases among staff· How many existing cases continue with diarrhoea and vomiting· Stool specimens submitted to the Microbiology Lab for Norovirus PCR, wherever

possible, before 11am to allow same day testing.· If no symptomatic cases, date & time of last episode· How many patients have not been affected?· How many empty beds (male & female).


· As soon as a patient is symptomatic in a bay all food and drink must be removed and thesurfaces cleaned with Actichlor 1,000ppm or Chlorox wipes. Water jugs and glasses mustbe put through the dishwasher.

· When an outbreak has been declared the nurse in charge must ensure that staff maintainaccurate stool and vomit charts on affected patients throughout the outbreak, including thedates and times of occurrence. If wards are amalgamated then this information must go withthe patients. This information assists the IPCD, to make a decision on when cleaning maycommence. The criteria we are looking for is 72 hours clear of symptoms.

· The Nurse in Charge must ensure that the ward doors are closed, and that the notices fromthe Infection Control outbreak box are displayed on the outer part of the doors asking allvisiting clinical staff and visitors to report to the Nurse in Charge.

· Where the ward/hospital has a thoroughfare, this must be closed during the outbreak.

· The Matron will attend the daily control meetings and feedback to the ward staff.

3.2 Domestic Services

As soon as a patient is symptomatic in a bay all food and drink must be removed and the surfacescleaned with Actichlor 1,000ppm/Clorox wipes. Water jugs and glasses must be put through thedishwasher.

When a ward is closed then Enhanced cleaning is required. The ward will re-open only after a deepclean (See Appendix 12 - with Actichlor plus 1,000ppm or after treatment with Hydrogen PeroxideVapour treatment). After the ward opens there must be Enhanced cleaning for a further 2 weeks.

Enhanced Cleaning

Extra cleaning of the toilets must be carried out 2 hourly throughout the day with Actichlor plus1,000 ppm and increase cleaning of other surfaces e.g. horizontal surfaces frequently touchedareas such as: door handles, soap dispensers, telephones, computer keyboards, etc. to 2 hourly).Staff changing areas must be cleaned and used linen removed at least twice a day. Out of hoursthe responsibility lies with the nursing staff.

3.3 Infection Prevention and Control Department (IPCD)

1. Carry out initial investigation of outbreak. Collect and collate information on affectedindividuals.

2. Attend the daily Control meeting giving up-to-date information.3. Consult with the DIPC/Consultant Microbiologist on whether to declare an Outbreak or

Increased Incidence.4. Inform Matron(s) and ward nursing and medical staff of the Outbreak or Increased Incidence.5. Inform Occupational Health Department on whereabouts of infected staff may be affected.6. Inform Facilities Manager/Supervisor of need to increase cleaning in the clinical area7. Advise on appropriate clinical/nursing control measures to prevent further spread of the

outbreak i.e. removing alcohol hand gel and advising the use of soap and water for handwashing.

8. Monitor implementation and effectiveness clinical/nursing control measures by observation ofpractice.

· Hand decontamination· Wearing & removal of appropriate personal protective clothing/scrubs· Safe disposal of clinical waste/laundry· Decontamination of the equipment and the environment using Actichlor plus

1,000ppm.


9. Liaise between the laboratory and the clinical areas regarding the collection and transport ofspecimens.

10. Inform the Laboratory of the outbreak and request sample are tested for Norovirus PCR(See also 4.8 Microbiology Laboratory).

11. Advise ancillary services as required.12. Prepare final report in conjunction with the DIPC within 1 month of outbreak being declared

over.

3.4 Director of Infection Prevention and Control (DIPC)

1. The DIPC will declare a Norovirus Increased Activity Meeting when there are more than 2cases in a single ward and /or more than 1 ward with cases and/or bay closed on a ward.When a ward is closed an outbreak meeting will be called.

2. Declare Outbreak or Increased Activity in consultation with IPCD.3. Inform Chief Executive, Medical Director, Director of Nursing and Quality and CCDC (PHE).4. Liaise with Medical Practitioners in charge of affected patients.5. Convene and chair Outbreak or Increased Activity meeting, if required.6. Arrange secretarial support and a venue for Outbreak or Increased Activity meeting.7. Co-ordinate and issue press release with the Communications Manager.8. Advise on the collection of specimens and arrange prompt processing by the Microbiology

Laboratory.9. Prepare final report in conjunction with the IPCD within 1 month of outbreak being declared

over.10. Complete and return a STEIS incident form if 3 wards or more are closed. The IPCD will

complete a DATIX form.11. The DIPC will inform Radiology /Theatres, etc. that patients from a closed ward must have

procedures / diagnostic tests and they can liaise with IP&C for advice.

4.0 Control Measures for Full Ward Closure

4.1 Admissions

Once an outbreak has been identified there are to be no admissions to the ward clinical area untilinstructed by the IPCD. However, if bed pressures are such that admission must occur, thisdecision can only be made by the DIPC/Consultant Microbiologist.N.B. This does not mean that the ward is completely re-opened. Discharges other than tohome or requiring carers/social services must not resume.

Partially opening a Closed Ward to admissions

In extreme circumstances when there are numerous patients awaiting in the A&E Department andthe environment there is unsafe, having reviewed and wherever possible cancelled elective surgery,then the Consultant Microbiologist can be consulted on about admitting patients onto a closed ward.The staffing levels on the closed ward must be such that it would be safe for patients to be admitted.The checklist for admitting to a closed ward Appendix 5 will be completed by the Control Team toensure patient safety. Patients and relatives will be given information about this and have theoption to refuse. Appendix 6.


4.2 Movement of Staff

There should be no movement of any staff without advice from the IPCD. (Unless they have beenoff duty for at least 72hrs and are asymptomatic)

If possible Bank and Agency staff must be booked for the affected area throughout the outbreak.Where there is an acute shortage of bank staff they may need to work in other clinical areas. Thesestaff must change into a clean uniform and inform IPCD if they develop diarrhoea and/or vomitingwhile working in another clinical area.

If a bank nurse becomes symptomatic after working in an affected area then they must contactEmployment Plus (see appendix 7).

4.3 Discharges to other Wards/Departments, Nursing and Residential Homes or PatientsOwn Home

There is to be no movement of patients without advice from the IPCD. Only in an emergency canthe Consultant in charge of the patients care risk assess and make the decision to move a patient toanother area. If this occurs the IPCD must be notified to implement the appropriate controlmeasures.

Patients may be discharged to their own home on medical advice, if they require socialservices/district nursing then the algorithm should be followed (appendix 8). If a patient isdischarged to their own home then the patient and their relatives must be given advice on themanagement of symptoms by the nurse in charge should they develop Norovirus and documentedin the notes.

Patients must not be transferred to other hospitals, nursing or residential homes as this willperpetuate the problem. Under extreme circumstances the decision may be made to transferpatients to residential/nursing home, the IPCD must be informed to give advice. However, topromote safe discharge patients waiting for assessment from home owners, the patientsmust be visited and assessed. To facilitate this, the ward manager, with advice frominfection control, will create a clean visiting area for assessments to be completed.

4.4 PortersThe Facilities Supervisor via the Facilities Management Helpdesk Ext 55331(External 01803 65531)must be informed by IPCD of the outbreak and necessary precautions required. Porters mustcontinue to transfer patients to other departments as necessary and the nurse in charge willensure there is a trolley with gloves, aprons, waste bag and detergent wipes near the ward entranceso that wheelchairs and trolleys can be wiped on leaving the ward. Education will be given by theIPCD regarding Norovirus.

4.5 Transfer of Patients to Departments for Procedures/Appointments

Patients may require treatment /procedures outside of the affected ward. This should not becancelled owing to the outbreak however the IPCD must be informed to minimise the risks. A riskassessment should be performed taking into account the following;

· Whether the patient has symptoms· How urgent the procedure or test is.· What precautions are required by the receiving department

The patient, where possible must be placed on the end of the list and transferred on a trolley orwheelchair not bed.


4.6 Support servicesAll usual care and investigations such as ECG and phlebotomy etc must continue throughout theoutbreak. The person concerned must change into theatre scrubs and take only the essentialequipment required and clean the equipment prior to leaving the ward. Where possible thephlebotomists should have a designated trolley that can be left on the ward during the outbreak.Whenever possible, these investigations must be done last. For further information, contactInfection Control. Education will be given by the IPCD regarding Norovirus.

Community Hospital ward staff can continue to carry out these investigations as normal during anoutbreak.

4.7 Visitors

Visitors must be informed of the infection risk and given an information leaflet See Appendix 11. It isadvisable that if a visit is not essential then this should be discouraged. To help ward staff advisevisitors there is an algorithm to follow in Appendix 9. Visiting by frail or very young persons shouldbe discouraged. Visitors must wash their hands with soap and water on entering and leaving theward.

4.8 Microbiology Laboratory and Norovirus Testing Requests

The Norovirus PCR testing of stool is done daily in the Microbiology lab at TSDFT from 9am to5:30pm, 7 days a week. Positive Norovirus results are emailed out by TSDFT Data office, to theIPCD, and are also booked onto the IPCD’s list. At the weekends and bank holidays the lab willtelephone the positive Norovirus result, to the consultant microbiologist. However, negative resultsshould not always be relied on as excluding an outbreak as the Sydney 2012 strain can give a falsenegative. A thorough risk assessment is still needed.

Sporadic testing (not part of outbreak) on wards that are not EAUs or A&E

If a patient is suspected of having Norovirus then the IPCD, or at the weekends and bank holidaysthe consultant microbiologist, must be contacted to make a decision on whether to test forNorovirus. This also applies to Community Hospital Wards.

Sporadic testing (not part of outbreak) on wards that are not EAUs or A&E

If a patient is suspected of having Norovirus (See Appendix 2; Green Form states recent diarrhoea& vomiting or recent contact with diarrhoea & vomiting) then the EAU or A&E staff can requestNorovirus testing.

Testing as part of an outbreak

Once a ward or a bay is shut and already has a positive Norovirus PCR result then the ward staffcan request Norovirus testing for any further patients affected on that ward.

Collated by Clinical Effectiveness Outbreaks of Viral Diarrhoea and / or Vomiting, the Management ofVersion 13 (April 2021) Page10 of 36

5.0 Infection control Precautions5.1 Hand HygieneStaff

Hands must be washed with soap and water throughout the outbreak as alcohol hand gel is noteffective against viruses such as Norovirus.

Staff are recommended to change out of their contaminated scrubs before eating their meals in thestaff room, to reduce the risk of contaminating their food. Eating and drinking in the clinical area isnot allowed.

Patients

Hands must be washed:

· Following use of the toilet· Prior to meals

If a patient is unable to access hand washing facilities, hand wipes must be offered.

Visitors

All visitors to the outbreak area must wash and dry their hands prior to entering and leaving theward. A notice to this effect must be prominently displayed inside the ward doors.

5.2 Protective Clothing

Designated coloured theatre scrubs will be made available. Please contact the FacilitiesManagement Help Desk Ext 55331 to arrange delivery

· Scrubs must be worn by permanent staff on the ward, if you are having direct patient contactor are in the area for more than an hour. For all other staff, apron and gloves must be worn.

· If you have clinical contact: use a new apron / gloves for each patient episode (Theseare available on the ward).

· If you do not have clinical contact, wear apron / gloves. You are welcome to change intoscrubs if you are going to be on the ward for a long time.

· Please report to the nurses’ station for further advice.· Wash your hands on entering and leaving this ward and after every patient contact.

Scrubs must not be worn outside the affected area unless it is the initial day of the outbreak andstaff have no alternative clothes.

A designated area for changing clothes i.e. bathroom, must be allocated during the outbreak andused only for this.

5.3 Linen

All linen from affected areas should be placed in a water soluble bag then placed in a red outerplastic linen bag.


6.0 Control Measures for Bay Closures

6.1 Admissions

Once a bay has been closed there are to be no admissions to this area until instructed bythe IPCD.However, if bed pressures are such that admission must occur, this decision can only bemade by the DIPC/Consultant Microbiologist.N.B. this does not mean that the closed bay is completely re-opened and dischargesother than to a patient’s own home must not resume.

Please use the Bay Closure Sign in Appendix 10.

6.2 Discharges to other Wards/Departments, Nursing and Residential Homes or patientsown home.

There is to be no movement of patients on the whole ward without advice from the IPCD. Only inan emergency can the Consultant in charge of the patients care risk assess and make the decisionto move a patient to another area. If this occurs the IPCD /CICT must be notified to implement theappropriate control measures.

All patients on the ward (not only the closed bay) may be discharged to their own home on medicaladvice, if they require social services/district nursing then the algorithm should be followed(Appendix 8). If a patient is discharged to their own home then the patient and their relatives mustbe given advice on the management of symptoms by the Nurse in Charge should they developNorovirus and documented in the notes.

Patients must not be transferred to other hospitals, Nursing or Residential Homes as this willperpetuate the problem. Under extreme circumstances the decision may be made to transferpatients to residential/nursing home, the IPCD must be informed to give advice.

6.3 PortersThe Facilities Supervisor via the Facilities Management Helpdesk Ext 55331 (external 01803655331) must be informed by IPCD of the bay closure and necessary precautions required. Portersmust continue to transfer patients to other departments as necessary and will be advised bythe nurse in charge on the precautions required. Education will be given by the IPCD regardingNorovirus. Porters in Community Hospitals will be informed by the affected wards co-ordinator.

6.4 Transfer of patients to Departments for Procedures/Appointments.

Patients may require treatment /procedures outside of the affected bay/ward. If this happens thenthe IPCD must be informed to minimise the risks. A risk assessment should be performed takinginto account the following;

· Whether the patient has symptoms· How urgent the procedure or test is.· The precautions required by the receiving department.

The patient, where possible must be placed on the end of the list, transferred on a trolley orwheelchair not in a bed.

6.5 Support Services

All usual care and investigations such as ECG and phlebotomy etc must continue. The personconcerned must wear apron and gloves and take only the essential equipment required and cleanthe equipment prior to leaving the ward. Whenever possible, these investigations must be done last.


For further information, contact Infection Control. Education will be given by the IPCD regardingNorovirus.

Community Hospital ward staff can continue to carry out these investigations as normal during anoutbreak.

6.6 Protective Clothing/measures

· Apron and gloves must be worn and a new apron / gloves for each patient (These areavailable on the ward). If staying more than an hour, change into scrubs and useapron/gloves for each patient.

· Please report to the nurses’ station for further advice.· Wash your hands on entering and leaving the bay and after every patient contact.

6.7 Patients

Hands must be washed with soap and water:

· Following use of the toilet· Prior to meals

If a patient is unable to access hand washing facilities, hand wipes must be offered.

6.8 Visitors

Visitors must be informed of the infection risk and given an information leaflet (appendix 11). It isadvisable that if a visit is not essential then this should be discouraged. (see visitor risk assessmentalgorithm appendix 8) Visiting by frail or very young persons should be discouraged. Visitors mustwash their hands with soap and water on entering and leaving the ward..All visitors/staff to the outbreak area must wash and dry their hands prior to entering and leaving theward. A notice to this effect must be prominently displayed inside the ward doors.

7.0 Staff Sickness

Any staff that becomes unwell should be sent home with a specimen pot and Infection Controlinformed. Staff must refrain from working until 48hrs clear of symptoms.

8.0 Criteria for re-opening a Bay/Ward

The bay/ward will be reopened by the Infection Prevention and Control Department when thefollowing criteria are met:

· No new cases of diarrhoea and/or vomiting and symptomatic patients have had no diarrhoeaand/or vomiting for 72hrs in the open ward.

· The bay/ward has been deep cleaned throughout and the control team, ward manager, andfacilities supervisor have signed off the deep cleaning procedure ( Appendix 12 )

A Declaration is made at the end of an outbreak by IP&CD.

This is the point at which terminal cleaning has been completed. Often, there are a small number ofpatients with persistent symptoms and it is advisable to isolate. Symptomatic patients may bemoved into single rooms on the affected ward. There is thought to be little risk of prolonged airbornepersistence of virus and terminal cleaning of an area such as a ward can commence 72hrs after


removal of symptomatic patients. (Bays may have been deep cleaned during the outbreak tofacilitate moving patients to a clean environment reducing their risk of catching the virus)

If bed pressures are such that admissions must occur, this decision can only be made by theDIPC/Consultant Microbiologist

9.0 Responsibility of Key Staff during Terminal Cleaning.

Please refer to deep cleaning protocol and procedure for more information in Appendix 13

9.1 Nursing Staff

· draft in extra nursing staff if required to assist with cleaning and movement of patients· Where possible, a bay should be emptied to allow for decanting of patients and cleaning.· Strip all bed linen, cleaning the mattress and unzipping checking for strikethrough and

damage to pillows.· Clean medical equipment· Inform the stores department to ensure adequate supplies are available for the ward· Inform the Medical Library & Tissue viability if more pressure relieving mattresses are

required.

9.2 Facilities Manager /Supervisor

· Co-ordinate deep cleaning team and ward cleaning teams· Ensure sufficient supplies of disposable curtains and linen for affected areas.

9.3 Facilities

Cleaning of all areas as per Trusts Deep Cleaning Procedure using appropriate cleaning materialsadvice will be given by the Facilities Manager. Curtains must be changed in all areas.

9.4 Estates Department Services

Removal of radiator covers only.

9.5 Stores

Ensure adequate supplies of products that will be disposed of during the terminal clean areavailable for the ward area.

ReferencesGuidelines for the management of norovirus outbreaks in acute and community health and socialcare settings. Produced by the Norovirus Working Party: an equal partnership of professionalorganisations for HPA March 2012.

http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1317131639453

Department of Health (2009). The Health Act 2008. Code of Practice for the Prevention and Controlof Health Care Associated Infections. London: Crown Copyright.

Report of the Public Health Laboratory viral gastroenteritis Working Group, management of HospitalOutbreaks of Gastro-enteritis due to small round structured viruses. Journal of Hospital Infection(2000) 45:1-10

http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1317131639453


Appendix 1

TORBAY AND SOUTH DEVON NHS FOUNDATION TRUST

NOROVIRUS ESCALATION TRIGGERS AND ACTION PLAN

2017/18

Acute Trust(Hospital)

CommunityCases

Action Responsibility

Preparednessand LongTermPlanning

No Cases No Cases

Ensure Diarrhoea and vomiting riskassessments are being completed onadmission to the Trust by undertakingweekly audit and prompt feedback

Infection Prevention and Control Department

Arrange Norovirus preparednessmeeting before the end of September

Infection Prevention and Control Department

Develop a public warning andinforming strategy

Communications team in consultation with PublicHealth

Review surge capacity and the needfor, and availability of, staff support inthe event of a Norovirus outbreak

Head of Operations

Head of Hospital Bank

Distribution of Norovirus advice andguidance to managers with particularregard relating to patient managementand staff movement

Infection Prevention and Control Department viacommunications Team and Team brief


Level 1GREEN


CommunityCases


OPEL 1

Business asUsual

None

Cases beingreported incommunity andneighbouringTrusts orNorovirus positiveresult from TorbayMicrobiology

Ensure Diarrhoea and vomiting risk assessments are being completedon admission to the Trust by undertaking weekly audit and promptsame day feedback

Infection Preventionand ControlDepartment

Implement Isolation, Management of Norovirus / D&V OutbreakManagement Policy

Acute Trusts,Community healthcareproviders

Prepare to implement Public Communications Strategy Communications team

Implement additional control measures (enhanced cleaning. Handwashing in affected areas)

FacilitiesManager/InfectionPrevention and ControlDepartment

Increase advice to healthcare professionals Infection Preventionand ControlDepartment

Maintain a watching brief and prepare to call an increased activitymeeting to consider implementing enhanced cleaning of public areas;green risk assessment form; communications to public and staff. .

InfectionControl/ControlDepartment


Level 2AMBER


CommunityCases

ActionAs above PLUS:

Responsibility

OPEL 2

More than 2cases in asingle ward and/or more than 1ward with casesand/or bayclosed on award

Cases in nursingresidential homesand/or schools(If1 communityhospital affectedGo to red status)

Ensure Diarrhoea and vomiting risk assessments are being completedon admission to the Trust by undertaking weekly audit and promptsame day feedback.




Review elective admissions and non-essential activities.

Review patients for early discharge with emphasis on patients suitablefor transfer to community hospitals.

Review use of social services residential homes and care packages

Review use of local non-NHS nursing homes.

Call Norovirus Enhanced Activity Meeting

Head of Operationsthrough the controlroom function

DIPC

Implement additional control measures (enhanced cleaning, cohortnursing)

FacilitiesManager/InfectionPrevention and ControlDepartment



Notify Strategic Health Authority Infection Preventionand ControlDepartment

Prepare to implement SITrep Reporting Performance Team

Implement Public Warning and Informing Strategy Communications teamin conjunction withpartner agencies


Level 2AMBER


CommunityCases

ActionAs above PLUS:

Responsibility

Brief Executive Control team

Maintain a watching brief and prepare to implement weekly infectioncontrol operational management meetings

InfectionControl/ControlDepartment

Invoke restrictive visiting arrangements. Control Team

The Consultant Microbiologist / DIPC (Director of Infection Preventionand Control) & Lead IP&CN will call an ‘Enhanced Activity Meeting’, tomake decisions as to cohorting or escalation facilities based on OPELtriggers.

DIPC Head ofOperations


Level 3RED


CommunityCases


OPEL 3 One wardclosed. As Amber

Ensure Diarrhoea and vomiting risk assessments are being completedon admission to the Trust by undertaking weekly audit and promptsame day feedback.


Consider cancelling elective surgery (except cancer and urgent) Control Meeting



Police restrictive visiting arrangements ensuring policy is beingfollowed correctly and inform affected patients next of kin

Matrons

Implement use of Social Services residential homes, care packages Acute Trust inpartnership with PCTs

Implement use of local non NHS nursing homes, private healthcare Acute Trust inpartnership with localPCTs

Commence formal daily Outbreak Management Team Meetings Infection Preventionand ControlDepartment

Continue SITREP Reporting Performance team

Continue On – Call Directors and Chief Executive Officer briefings Control RoomFunction

Maintain outbreak communications cascade to all clinical areas partneragencies

Communication Team/ Infection Preventionand ControlDepartment

Maintain Public Warning and Informing messages Communication Team


Level 4INTERNALMAJORINCIDENT


CommunityCases


4(InternalMajorIncident)CriticalServiceDisruption

2 or more wardsclosed.

As Amber plusneighbouringTrusts

Cancel all elective surgery (except cancer and urgent) Control Room

Continue SITREP Reporting Performance Team

Continue with Outbreak Management Team Meetings under thestrategic direction of the CEO’s.

Executive Lead

Continue SITREP Reporting

Continue On – Call Directors and Chief Executive Officer briefings Infection Preventionand ControlDepartment/ControlRoom

Maintain outbreak communications cascade to all clinical areas partneragencies

Communications team/Infection Preventionand ControlDepartment

Maintain advice and guidance to health and social care workers Infection Preventionand ControlDepartment

Maintain Public Warning and Informing messages Communication Team

Collated by Clinical Effectiveness Outbreaks of Viral Diarrhoea and /Version 13 (April 2021) or Vomiting, the Management of

of 36

Appendix 2

Linked to Clinical Forms Library

Infection Prevention and Control Risk Assessment

https://icon.torbayandsouthdevon.nhs.uk/corp_doc_mgmt/Clinical%20Effectiveness/Infection%20Prevention%20and%20Control%20Risk%20Assessment%20V5.0.pdf

IC Record Sheet - PATIENTS with Diarrhoea (D) and Vomiting (V)Initial Assessment FormWARD / HOSPITAL: DATE OUTBREAK STARTED:


BEDNO.

SURNAME (WRITECLEARLY CAPS)

FIRST NAME(WRITE CLEARLY

CAPS)DOB

HOS NO.AND / ORNHS NO.

ADMITTEDFROM &

DATEADMISSIONDIAGNOSIS

STOMACHCRAMPS

(Y/N)DATE

STARTED(D)

(Y/N)(V)

(Y/N)SPECSENT

APPENDIX 3

IC Record Sheet - PATIENTS with Diarrhoea (D) and Vomiting (V)Initial Assessment FormWARD / HOSPITAL: DATE OUTBREAK STARTED:


BEDSPACE


FIRST NAME (WRITECLEARLY CAPS)

HOS NO.AND / ORNHS NO.

DATESTARTED

(D)(Y/N)

(V)(Y/N) DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6

IC Record Sheet - STAFF with Diarrhoea (D) and Vomiting (V)Initial Assessment FormWARD / HOSPITAL: DATE OUTBREAK STARTED:



FIRST NAME(WRITE CLEARLY

CAPS)JOB TITLE DOB DATE

STARTEDSYMPTOMSAT WORK

DATEFINISHED

(D)(Y/N)

(V)(Y/N)

STOMACHCRAMPS

(Y/N)SPECSENT

IC Record Sheet - VISITORS with Diarrhoea (D) and Vomiting (V)

WARD / HOSPITAL: DATE OUTBREAK STARTED:


SURNAME (WRITE CLEARLYCAPS)

FIRST NAME (WRITECLEARLY CAPS)

DOB VISITING DATESTARTED DATE FINISHED (D)

(Y/N)(V) (Y/N)

STOMACHCRAMPS (Y/N)

SPEC SENT

DATE OUTBREAK STARTED:


Deep Clean Record Date:

Completion ConfirmedFacilities Management:

Senior Ward Staff:

HPV

Actichlor


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Appendix 4WARD _______________

Outbreak Control Measures To Be Relayed To All Staff By TheNurse In Charge/Co-Ordinator.

Ward/Bay

o Close ward or bay to admissions and transfers

o Keep doors to side-rooms, bay and ward doors closed

o Place signage on the ward door/bay informing all visitors and staff of the closed statusand restricting visits to essential staff and patient visitors only

Healthcare Workers (HCWs)

o Ensure all staff are aware of the Norovirus situation and how Norovirus spreads

o Ensure all staff are symptom free

o Implement no eating/drinking in clinical area

Patient and Relative Information

o Provide all patients and relatives with information on the Norovirus situation andnecessary control measures they should follow

o Advise relatives of the personal risk and how to reduce this risk and advise not to visitunless absolutely necessary

Continuous Monitoring and Communications

o Maintain an up to date record of all patients with symptoms and the numbers of staff andrelatives affected

o Ensure information is available for infection control team at 9am

o Commence Bristol stool charts for all patients

o Send specimens to lab


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Personal Protective Equipment (PPE)

o Allocate dedicated changing room and arrange signage

o Change into scrubs as per policy

o Use gloves and apron between all patients

o Twice daily check PPE removed correctly between patients and hands washed

Hand Hygiene

o Remove alcohol hand gel

o Use liquid soap and warm water as per 5 moments

o Encourage and assist patients with hand hygiene before eating/drinking and after use oftoilet

o Check hand hygiene wipes outside sluice

Environment

o Remove exposed foods, e.g. fruit bowls

o Contact Facilities Supervisors to ensure enhanced cleaning as per policy. Report anyissues to Infection Prevention and Control

o Decontaminate frequently touched surfaces with Clorox wipes

o Use dedicated toilets or commodes for affected patients

o Check commode sign off daily

o Orange bin bags in place

PLEASE CHECK DAILY THAT THESE MEASURES ARE IN PLACE

Signature: _____________________________

Date: ______________________________


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TWICE DAILY CHECK FOR HAND HYGIENE AND PPE

Apron and gloves used between patients YES NO

Apron and gloves removed correctly between YES NOPatients (Gloves then hand hygiene and thenapron and then handHygiene)

Action taken if any answers are NO ____________________________

______________________________________________________________________________

______________________________________________________________________________

TWICE DAILY CHECK FOR HAND HYGIENE AND PPEWARD DATE TIME

Apron and gloves used between patients YES NO

Apron and gloves removed correctly between YES NOPatients (Gloves then hand hygiene and thenapron and then handHygiene)

Action taken if any answers are NO ___________________________

______________________________________________________________________________

______________________________________________________________________________

WARD DATE TIME


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Appendix 5CHECKLIST FOR WHEN A WARD IS CLOSED DURING

AN OUTBREAK OF VIRAL DIARRHOEA AND VOMITINGAND THE DECISION TO ADMIT BY THE ON-CALLMANAGER AND CONSULTANT MICROBIOLOGIST

Documentation of Decision of the Control Team

1. Have areas been cleaned adequately to reduce risk ofinfection.(see ward cleaning programme: critical areas cleanede.g. sluice, toilets, public areas around Bay beingopened)

□Action

………………

2. Clear verbal communication to be sent to Matron/WardManager or nurse in charge of the ward out of hours,Medical Staff, Bed Flow Team. To be followed up byconfirmation email.

□Action

………………

3. Information given to relatives and patients by 104/110on-call managers (Community Staff call 01803 614567and ask for 104/110). Both verbal and written.(Template in escalation folder control room &Appendix 6 in this policy)

□Action

………………

4. Adequate staff to nurse patients separately and safelyreducing risk of infection. 104/110 discussion withward as to requirements.

□Action

………………5. Allocation of patients: in consultation with clinical

staff and the 104 to assess appropriate patients to beadmitted/transferred to the closed area. Withparticularly consideration given not to move medicalor mentally vulnerable patients.

□Action

………………

6. Decision to admit was made by:-Head of Operations/On-Call Executive□…………………………………….With full agreement ofDIPC or Consultant Microbiologist/Lead Infection Control Nurse□…………………..□………………….. Operational Manager to inform ExecutiveOn-Call


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Appendix 6

Patient Letter For Admission To A Closed Ward.

Dear Patient.

You will be aware that hospitals are under great pressure from Norovirus. This viruscauses vomiting and diarrhoea and is spread by virus being released into the air in vomit.To control Norovirus in hospitals we close wards to new admissions and do not sendpatients, from the closed ward, to other wards or hospitals until all patients have had nosymptoms for 72 hours.

When we have a ward or more than one ward closed especially in the busy winter periods,we may not have enough beds for all the emergency admissions.

We are experiencing this difficulty now, and to allow you to be admitted into a bed it isnecessary to send you to a ward that is in the process of being cleaned after an outbreak ofdiarrhoea and vomiting. We have deep cleaned the bay you will be admitted to andsurrounding areas reducing your risk of contracting this virus. We will have separatenursing staff caring for you during this time. If you have any concerns about being admittedto this ward please let the nurse in charge of your care know.

Your senior nursing staff will explain to you that there may be some restrictions on visitornumbers and times to try and prevent visitors from catching Norovirus on the ward. Wehave produced an information leaflet about Norovirus which is attached to this letter.

Please accept my sincere apologies for any inconvenience caused.

Yours sincerely

Chief Nurse


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Appendix 7

IF A BANK NURSE BECOMES SYMPTOMATIC AFTER WORKING IN AN AFFECTED AREATHEN THEY MUST CONTACT EMPLOYMENT PLUS

This policy outlines what should happen in the event of a temporary worker who is booked for shifts

or has given availability but is unable to complete them due to having worked in a closed ward area

and contracting the current virus.

As healthcare staff within the organisation we have a duty of care to our patients & refusing to work

in infected areas is in breach of our Professional Code of Conduct. This duty of care is related to

Qualified and Unqualified Staff.

Criteria:

· Must have worked in the hospital on a closed infected area in the previous 72 hours, or since

that shift the ward has now become infected.

· Must have contacted Employment-Plus (01803 653348) and Infection Control (01803

655757) when first displaying symptoms of Diarrhoea and Vomiting. If displaying these

symptoms prior to working must phone Infection Control for advice before entering the

hospital premises.

· In order to qualify for any payment whilst off sick during this time temporary workers will

need to have either availability already recorded in the system when notifying Employment-

Plus/Infection Control of their illness or have shifts pre-booked with Employment-Plus.

· Staff on a temporary placement will need to provide evidence of shifts worked and planned.

Infection Control will confirm when you can proceed to working within the organisation.

Infection Control will inform Employment-Plus when payment should be authorised.

Maria Stone will maintain a database of such staff and areas where they were due to work. All

timesheets need to be signed off by Maria Stone, indicating what the payment is for before

forwarding to Payroll.

N.B. this does not apply unless the bank worker hasworked on a closed ward.

HR Director of Human Resources


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Appendix 8

RISK ASSESSMENT ALGORITHM FOR PATIENTS REQUIRINGDOMICILIARY CARE/COMMUNITY NURSING/INTERMEDIATE CARE

Risk Assessment for patients requiring Outreach/Carers/Community Nurses on discharge from a restricted ward due to diarrhoea and/or vomiting

Has the patient had diarrhoea and/or vomiting and resolved?

Any relatives symptomatic

Visit as planned no further action

If the visit is essential/critical consider leaving until final planned visit; always use PPE, e.g. aprons/gloves and wash hands with soap and water.

Re-schedule the visit and phone daily to

check if symptomatic for the first 72 hours

Is the visit essential / critical?

YesNo

No

YesYes

No


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Appendix 9

VISITOR RISK ASSESSMENT ALGORITHMThe Infection Prevention and Control Department/Community Infection Control Team is askingwards for their support in restricting visiting. The reason for this is that Norovirus is currently veryevident in the local community, and may be brought in by visitors starting outbreaks on thewards. Please use this algorithm to risk assess visitors when they call or visit the ward:

If your ward is Open to Admissions and currently free of the virus, advise any visitors:

· Tell us if you feel at all unwell at any time during your visit· Please refrain from using any toilets on the ward· Please wash your hands with soap and water on entering the ward, and again when you

leave

If your ward is currently affected by the virus, advise any visitors:· Please wash your hands with soap and water on leaving· Importantly, do not visit any other parts of the hospital – leave by the nearest exit


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Appendix 10

BAY CLOSED· Please wear apron and gloves when

looking after patients· Remember to change apron and gloves

between patients· Designated patient equipment to be used

in this bay· Clean any equipment which has to be

removed from the bay with Clorox wipes· Wash hands with soap and water

between patients and on leaving bay


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Appendix 11Linked to Patient Information Leaflet 22086 - Norovirus: The facts about

http://www.torbayandsouthdevon.nhs.uk/uploads/22086.pdf

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Appendix 12

DEEP CLEANING PROCEDURE

When a bay becomes empty on a ward the deep cleaning team will commence cleaning. The bay will be cleaned with detergent and water to prepare forhydrogen peroxide vapour treatment. The decision for the product used will be made by the IPCD / DIPC and entered on ward plan (see example below). Thiswill be confirmed at the control meeting out of hours by the on call microbiologist via switchboard. All areas must be signed off by nurse in charge and facilitiessupervisor prior to reopening. The bleep 104/on call manger must check that this has happened.

Colour coding for cleaning method

Actichlor 1,000ppm

Hydroproxide Vapour


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Appendix 13

GUIDELINES FOR THE TERMINAL CLEANING OF A WARD FOLLOWINGAN OUTBREAK OF INFECTION

1. The decision to terminally clean and reopen a ward/area will be made by the Director ofInfection Prevention and Control (DIPC) or deputy once the Infection Prevention and ControlDepartment (IPCD) has advised that the patients and staff in the affected area do not posean infection risk to new admissions.

2. The IPCD will endeavour to give 24 hours’ notice that a clean is likely. This should allowarrangements to be made for adequate numbers of staff to be available.

3 Facilities Management will require 3 days to terminally clean a ward and associated roomsby deploying 4 members of staff between 08:00 –20:00 hours.

4. Confirmation that terminal cleaning can proceed will be given at the Daily 10:00.OperationalMeeting.

5 A terminal clean co-ordinator must be identified by the Associate director of nursing or oncall manager which must be the ward manager or Matron/Matron of the week who will beresponsible for ensuring that the terminal clean is carried out correctly in accordance withprocedures whilst minimising disruption to patient care. The co-ordinator must be familiarand have had training with the cleaning standards required for a terminal clean.

6 An Infection Control Nurse will ensure that clear instruction is given to the nominated co-ordinator regarding the extent of the clean, products to be used and movement of patients.

7 The co-ordinator will:· Ensure adequate nursing staff are available and order bank if required· Identify how many facilities staff and nursing staff are available, what time they are

due to finish their shift and how long they are entitled to take for their breaks andcoordinate

· Identify nursing staff to work with the facilities staff and others to provide patient care.· Obtain scrub suits for staff to wear whilst cleaning.· Ensure that all parties involved in the clean are familiar with the terminal cleaning

procedure and products to be used.· Identify the order in which the various parts of the ward will be cleaned.· Ensure that patients are moved as early in the day as possible out of the area where

cleaning will start.· Keep the Infection Control Team, Operations Team and Matron informed of progress,

identifying the need for additional support if required.· Sign off the cleaning checklist at the end of the clean to ensure that all aspects of the

terminal clean have been completed. If satisfied that the clean has been completed,sign off this form and inform the on call senior manager that admissions can beresumed.

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Document Control Information


This is a controlled document and should not be altered in any way without the expresspermission of the author or their representative.

Please note this document is only valid from the date approved below, and checks shouldbe made that it is the most up to date version available.

If printed, this document is only valid for the day of printing.

This guidance has been registered with the Trust. The interpretation and application ofguidance will remain the responsibility of the individual clinician. If in doubt contact a seniorcolleague or expert. Caution is advised when using clinical guidance after the review date,or outside of the Trust.

Have you identified any issues on the Rapid (E)quality ImpactAssessment. If so please detail on Rapid (E)QIA form. Yes ☐

Please selectYes No

Does this document have implications regarding the Care Act?If yes please state: ☐ ☐

Does this document have training implications?If yes please state: ☐ ☐

Does this document have financial implications?If yes please state: ☐ ☐

Is this document a direct replacement for another?If yes please state which documents are being replaced: ☐ ☐

Ref No: 0653Document title: Outbreaks of Viral Diarrhoea and/or Vomiting, Management ofPurpose of document:Date of issue: 23 April 2021 Next review date: 23 April 2024Version: 13 Last review date: March 2021Author: Infection ControlDirectorate: Infection ControlEquality Impact: The guidance contained in this document is intended to be inclusive for

all patients within the clinical group specified, regardless of age,disability, gender, gender identity, sexual orientation, race and ethnicity& religion or belief

Committee(s) approvingthe document:

Infection Prevention and Control Committee

Date approved: 16 November 2017Links or overlaps withother policies:

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Document Amendment History

DateVersion

no.Amendment

summary Ratified by:February 2003 1 New Infection Control

Medical DirectorDirector of Nursing & Governance

23 October 2003 2 Amended Infection ControlMedical DirectorDirector of Nursing & Governance

2 September2004

3 Amended Infection ControlMedical DirectorDirector of Nursing & Governance

1 May 2008 4 Revised Director of Nursing & QualityDirector of Infection Prevention &Control

3 July 2008 5 Revised Director of Nursing & QualityDirector of Infection Prevention &Control

28 January 2010 6 Revised Director of Nursing & QualityDirector of Infection Prevention &Control

16 December2010

7 Revised Director of Nursing & QualityDirector of Infection Prevention &Control

25 November2011

8 Revised Director of Nursing & QualityDirector of Infection Prevention &Control

7 November 2013 9 Revised Director of Infection Prevention &ControlDirector of Professional Practice,Nursing and Peoples ExperienceDirector of Professional Practice in theCommunity

27 March 2014 10 Revised Director of Infection Prevention &ControlDirector of Professional Practice,Nursing and Peoples Experience

8 January 2016 11 Revised Director of Infection Prevention &ControlDirector of Professional Practice,Nursing and People’s Experience

9 February 2017 12 Revised Infection Control Committee16 February 2018 13 Revised Infection Control Committee23 April 2021 13 Date change Infection Control Committee

Collated by Clinical Effectiveness Outbreaks of Viral Diarrhoea and / or Vomiting, the management ofVersion 13 (April 2021) The Mental Capacity Act

The Mental Capacity Act 2005

The Mental Capacity Act provides a statutory framework for people who lack capacity tomake decisions for themselves, or who have capacity and want to make preparations for atime when they lack capacity in the future. It sets out who can take decisions, in whichsituations, and how they should go about this. It covers a wide range of decision makingfrom health and welfare decisions to finance and property decisions

Enshrined in the Mental Capacity Act is the principle that people must be assumed to havecapacity unless it is established that they do not. This is an important aspect of law that allhealth and social care practitioners must implement when proposing to undertake any actin connection with care and treatment that requires consent. In circumstances where thereis an element of doubt about a person’s ability to make a decision due to ‘an impairment ofor disturbance in the functioning of the mind or brain’ the practitioner must implement theMental Capacity Act.

The legal framework provided by the Mental Capacity Act 2005 is supported by a Code ofPractice, which provides guidance and information about how the Act works in practice.The Code of Practice has statutory force which means that health and social carepractitioners have a legal duty to have regard to it when working with or caring for adultswho may lack capacity to make decisions for themselves.

All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy,Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment,checklists and Independent Mental Capacity Advocate referral forms on ICON.

https://icon.torbayandsouthdevon.nhs.uk/areas/mental-capacity-act/Pages/default.aspx

Infection Control

All staff will have access to Infection Control Policies and comply with the standards withinthem in the work place. All staff will attend Infection Control Training annually as part oftheir mandatory training programme.

“The Act is intended to assist and support people who maylack capacity and to discourage anyone who is involved incaring for someone who lacks capacity from being overlyrestrictive or controlling. It aims to balance an individual’sright to make decisions for themselves with their right to beprotected from harm if they lack the capacity to makedecisions to protect themselves”. (3)

https://icon.torbayandsouthdevon.nhs.uk/areas/mental-capacity-act/Pages/default.aspx

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Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies)

Policy Title (and number) Version and DatePolicy AuthorAn (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage peoplewhilst advancing equality. Consider the nature and extent of the impact, not the number of people affected.Who may be affected by this document?Patients/ Service Users ☐ Staff ☐ Other, please state… ☐

Could the policy treat people from protected groups less favourably than the general population?PLEASE NOTE: Any ‘Yes’ answers may trigger a full EIA and must be referred to the equality leads belowAge Yes ☐ No☐ Gender Reassignment Yes ☐ No☐ Sexual Orientation Yes ☐ No☐Race Yes ☐ No☐ Disability Yes ☐ No☐ Religion/Belief (non) Yes ☐ No☐Gender Yes ☐ No☐ Pregnancy/Maternity Yes ☐ No☐ Marriage/ Civil Partnership Yes ☐ No☐Is it likely that the policy could affect particular ‘Inclusion Health’ groups less favourably than the generalpopulation? (substance misuse; teenage mums; carers1; travellers2; homeless3; convictions; social isolation4;refugees)

Yes ☐ No☐

Please provide details for each protected group where you have indicated ‘Yes’.

VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusionIs inclusive language5 used throughout? Yes ☐ No☐ NA ☐

Are the services outlined in the policy fully accessible6? Yes ☐ No☐ NA ☐

Does the policy encourage individualised and person-centred care? Yes ☐ No☐ NA ☐

Could there be an adverse impact on an individual’s independence or autonomy7? Yes ☐ No☐ NA ☐

EXTERNAL FACTORSIs the policy a result of national legislation which cannot be modified in any way? Yes ☐ No☐What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?)

Who was consulted when drafting this policy?Patients/ Service Users ☐ Trade Unions ☐ Protected Groups (including Trust Equality Groups) ☐

Staff ☐ General Public ☐ Other, please state… ☐

What were the recommendations/suggestions?

Does this document require a service redesign or substantial amendments to an existing process? PLEASENOTE: ‘Yes’ may trigger a full EIA, please refer to the equality leads below

Yes ☐ No☐

ACTION PLAN: Please list all actions identified to address any impactsAction Person responsible Completion date

AUTHORISATION:By signing below, I confirm that the named person responsible above is aware of the actions assigned to themName of person completing the form SignatureValidated by (line manager) Signature

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Please contact the Equalities team for guidance:For Devon CCG, please email [email protected] & [email protected]

For Torbay and South Devon NHS Trusts, please call 01803 656676 or email [email protected] form should be published with the policy and a signed copy sent to your relevant organisation

Consider any additional needs of carers/ parents/ advocates etc, in addition to the service user2 Travelers may not be registered with a GP - consider how they may access/ be aware of services available to them3 Consider any provisions for those with no fixed abode, particularly relating to impact on discharge4 Consider how someone will be aware of (or access) a service if socially or geographically isolated5 Language must be relevant and appropriate, for example referring to partners, not husbands or wives6 Consider both physical access to services and how information/ communication in available in an accessible format7 Example: a telephone-based service may discriminate against people who are d/Deaf. Whilst someone may be able to act on theirbehalf, this does not promote independence or autonomy

mailto:[email protected]



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Clinical and Non-Clinical Policies – Data Protection

Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure thatall policies and procedures developed act in accordance with all relevant data protectionregulations and guidance. This policy has been designed with the EU General DataProtection Regulation (GDPR) and Data Protection Act 2018 (DPA 18) in mind, andtherefore provides the reader with assurance of effective information governance practice.

The UK data protection regime intends to strengthen and unify data protection for allpersons; consequently, the rights of individuals have changed. It is assured that theserights have been considered throughout the development of this policy. Furthermore, dataprotection legislation requires that the Trust is open and transparent with its personalidentifiable processing activities and this has a considerable effect on the way TSDFTholds, uses, and shares personal identifiable data.

Does this policy impact on how personal data is used, stored, shared or processed in yourdepartment? Yes ☐ No ☐

If yes has been ticked above it is assured that you must complete a data mapping exerciseand possibly a Data Protection Impact Assessment (DPIA). You can find more informationon our GDPR page on ICON (intranet)

For more information:· Contact the Data Access and Disclosure Office on [email protected],· See TSDFT’s Data Protection & Access Policy,· Visit our Data Protection site on the public internet.

https://icon.torbayandsouthdevon.nhs.uk/areas/gdpr/Pages/default.aspx


https://icon.torbayandsouthdevon.nhs.uk/areas/information-governance/Policies/TSDFT%20Policy%20Data%20Protection%20and%20Access.pdf

https://www.torbayandsouthdevon.nhs.uk/about-us/data-protection/