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Norovirus
Prevention & Management
Traci Treasure, MS, CPHQ, LNHA
Aimee Ford, RN, MS
December 17, 2015
Housekeeping Items
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Qualis Health
• A leading national population health
management organization
• The Medicare Quality Innovation Network - Quality
Improvement Organization (QIN-QIO) for
Idaho and Washington
The QIO Program
• One of the largest federal programs dedicated to
improving health quality at the local level
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Objectives
• Share norovirus outbreak stories and
lessons learned
• Discuss best practices for prevention
and management of outbreaks
• Explore areas for improvement
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Stories from the Field
Laura Showers
Critical Access Hospital
Port Townsend, WA
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Timeline and characteristics:
PATIENT HISTORY
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Multiple patients from Assisted Living to
ED night shift 11/14/14
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Patient admitted from Assisted Living
vomiting hyponatremia to room 307
11/14/14
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Second patient later on investigation
had been in the ICU 11/13/14 diarrhea,
vomiting
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Inpatient post op TKA in swing bed room
313 became ill, nausea, vomiting,
diarrhea 11/16/14 (possible HAI, healthy
and well pre-op)
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Second patient to ACU from Assisted
Living dehydration, diarrhea 11/16/14
room 321
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Third patient admitted 11/19/14 vomiting
diarrhea from Assisted Living 11/19/14
rm 322
STAFF HISTORY
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RN ICU 11/14/14 severe nausea, vomiting 11/14/14
to ED for rehydration
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RN ICU 11/15/16 severe nausea, vomiting, fever
11/15/14
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PTA Swing bed nausea, vomiting 11/16/14 afternoon
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CNA Swing bed nausea vomiting, sick 11/17/14
returned to work 11/18 felt ill, sick again 11/19
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RN ACU vomiting diarrhea evening shift 11/17/14
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CNA sick (unknown reason) night shift 11/17/14
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RN ACU nausea vomiting 11/17/14 (worked nights
11/16)
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RN ACU nausea vomiting 11/18/14
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RN Home Health nausea vomiting 11/19/14 after
visiting a patient at Assisted Living
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EMS staff, 2, report vomiting, diarrhea after
transporting patients from Assisted Living
•
No further staff illnesses were reported to EHN
hotline or tracked by House Supervisors
X:\Departments\Infection Control\Vomiting-diarrheal Illness Outbreak for EQuIP presentation 12-15
Confidential coordinated quality improvement program (CQIP)/ risk management/ peer review information under RCW
70.41.200/4.24.250/ 43.70.510. Do not disclose, reproduce, or distribute without permission.
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Investigation and actions
Verify the diagnosis and determine initial
magnitude
Confirm an outbreak exists and search for
additional cases
•
•
Done in consultation with Health Department,
number of cases of diarrheal and vomiting illness
greatly exceeds the norm both in patient and
staff.
•
All patient diarrhea work ups negative for Cdiff
and other pathogens (norovirus not tested).
Nausea, vomiting, enteric illness. Rapid
onset, severe symptoms.
Collaboration with stakeholders:
•
11/18/14 IP notified Health Department and
determined there was a severe outbreak of
vomiting and diarrheal illness at Assisted
Living.
•
PHD was working closely with them and they
had closed cafeteria and increased infection
prevention practices.
•
House Supervisors and staff alerted to use the
EHN hotline to report enteric illnesses. Multiple
cases listed above from that report.
•
IP notified HD of cases in staff and patients at
the hospital and got recommendations.
•
•
IP sent out clinical staff bulletin regarding
outbreak and steps to prevent transmission
(standard precautions, heightened hand
hygiene with soap and water, enteric
transmission based precautions for all
patients with nausea/vomiting/diarrhea)
encouraged to notify EHN if they have any of
these symptoms.
IP surveillance for inpatients with nausea,
vomiting, diarrhea and rounding daily to check-in
with staff regarding illness, compliance with
enteric precautions and reminders of apparent
virulence of the illness.
•
Hospitalist group and outpatient clinics notified.
•
Planning ensued with EHN who began
tracking staff illness.
X:\Departments\Infection Control\Vomiting-diarrheal Illness Outbreak for EQuIP presentation 12-15
Confidential coordinated quality improvement program (CQIP)/ risk management/ peer review information under RCW
70.41.200/4.24.250/ 43.70.510. Do not disclose, reproduce, or distribute without permission.
7
Investigation and actions
Determine characteristics of the cases
and a tentative hypothesis
Institute preliminary control measures and test-refine
hypothesis
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All cases originated from Assisted Living.
Transmission by contact to staff and
possibly 1 patient.
•
Done through electronic notifications, notification of
medical staff and executive leadership, notification of
employee health, notification of public health with
recommendations, routine surveillance and daily rounds
•
Norovirus was the likely cause; this was
discussed with the Public Health Nurse and
Assisted Living leadership who were using
this as a working case definition as well.
•
Hypothesis was not tested, control measures were not
refined as outbreak ceased after the case on 11/19
(control measures were apparently effective)
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Ongoing daily monitoring and reports from the House
Supervisors confirmed no further staff cases.
•
No cases were confirmed, all other illnesses
ruled out (Cdiff, campylobacter)
X:\Departments\Infection Control\Vomiting-diarrheal Illness Outbreak for EQuIP presentation 12-15
Confidential coordinated quality improvement program (CQIP)/ risk management/ peer review information under RCW
70.41.200/4.24.250/ 43.70.510. Do not disclose, reproduce, or distribute without permission.
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Stories from the Field
Lori Bentzler
Skilled Nursing Facility
Twin Falls, ID
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Best Practices Review
Jamie Moran, MSN, RN, CIC
Infection Preventionist
Quality Improvement Consultant
Qualis Health
206-288-2512
jamiem@qualishealth.org
NOT WANTED!
Dead or Alive
A very bad boy!
norovirus
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Recognition: Signs and Symptoms
Early recognition is critical to controlling spread!
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Transmission
• Highly contagious!
• Only 10 to 100 virion needed to cause disease
• Fecal-oral and contact transmission
• Evidence of aerosolization
• Environmental persistence
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•
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•
•
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21 to 28 days (dry, room temperature)
Detectable up to 5 months
7 days (dry at room temperature) on stainless steel
12 days in carpet (despite routine vacuuming)
> 72 hours on computer keyboards and mice
Can survive in temperatures up to 140◦ F
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Noro-readiness
Expect norovirus and prepare for it now!
• Proactive illness surveillance
• Monitor community
• Train and drill front-line workers
• Test communication systems
• Assess supplies
• Test hot-water systems
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Noro-readiness
Be ready to act!
• Have a high index of suspicion
• Ensure front-line staff are suspicious too
• At first sign of illness in a patient or resident – Isolate!
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Interventions
Outbreak?
• Two or more cases (epidemiologically linked)
• Kaplan’s Criteria
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Vomiting in >50% of cases
Mean incubation 24 to 48 hours
Mean illness duration 12 to 60 hours
No bacterial pathogens isolated in stool
• Implement outbreak containment strategies
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Interventions
Diagnosis and Treatment
• Work with public health early in suspected outbreak to
determine need for diagnostic testing
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Interventions
Consider modified FEMA incident command structure
for rapid and effective coordination
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Interventions
Staff
• Assign staff to one specific cohort of patients or residents, and
do not move between cohorts
Symptomatic
Exposed but
Asymptomatic
Unexposed
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Interventions
Staff Illness
• Stay home, go home
• Increase surveillance among ill employee’s contacts
• Stay home until 48 hours after symptoms have resolved
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Continue meticulous hand-washing
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Interventions
Visitors
• Create visitor policy now
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Interventions
Environmental Cleaning
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Interventions
Environmental Cleaning
• Dishware
• Upholstery
• Privacy curtains
• Linens
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Interventions
Patient Transfer and Ward Closure
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Interventions
Food Handling
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Interventions
Hand Hygiene
• Single most-important intervention
• Use soap-and-water as preferred method
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Stories from the Field
Jeanne Trepanier
Critical Access Hospital
Ephrata, WA
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Stories from the Field
Dave Brantley
Skilled Nursing Facility
Vancouver, WA
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Discussion and Q & A
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Take Home Points
• Expect norovirus!
• Be proactive with surveillance
• Test your systems before an
outbreak occurs
• Act quickly to contain spread
• Reach out to public health partners
for help
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Thanks and Appreciation
• Laura Showers
• Lori Bentzler
• Dave Brantley
• Jeanne Trepanier
• Jamie Moran
• Participating hospitals
• Participating long-term care facilities
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Contact
Traci Treasure
QI Consultant
TraciT@qualishealth.org
208-383-5947
Aimee Ford
QI Consultant
AimeeF@qualishealth.org
206-288-2567
For survey:
https://www.surveymonkey.com/r/XJ5K6SN
For more information:
www.Medicare.QualisHealth.org
This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization
(QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
ID/WA-QH-C2-2061-1215
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References and Resources
References
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CDC/HICPAC: Guideline for the Prevention and Control of Norovirus
Gastroenteritis Outbreaks in Healthcare Settings, 2011.
http://www.cdc.gov/hicpac/norovirus/005_norovirus-summaryOrecs.htm
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Lee, Lore Elizabeth (2011). Calicivirus outbreaks in long-term care
facilities. Oregon Health Authority. Available at
http://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/
Outbreaks/Documents/2013-norovirusOBs-LTCF.pdf
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