major incidents

Published: 30/01/2003, Volume II3, No. 5840 Page 26 27

The successful management of a virus outbreak in Berkshire ensured that disruption was kept to a minimum, despite one or two unexpected problems. Alison Browne and Adrian Dalby explain the procedure

In October last year, Reading's Royal Berkshire Hospital experienced a major incident as a result of the Norwalk-like virus which had affected many other hospitals in south-east England.

A total of 147 patients, more than 200 staff and 50 wards and departments were affected by the outbreak over a two-month period, the first cases being reported to the infection control team on 14 October. Several wards were closed to new admissions (apart from patients with the virus) during the outbreak as a result of the pressures caused by the sickness of ward staff and the inability to convince bank or agency staff to work in the affected areas.

In December last year, the Public Health Laboratory Service reported 3,029 confirmed cases of the virus in the first 10 months of 2002, a substantial increase over previous years.More than two-thirds of the cases were people aged 65 or above. Since 1992, over three-quarters of the outbreaks reported to PHLS occurred in hospitals or residential homes.

The virus is not specifically hospital acquired, but due to the vulnerability of some of the patients with chronic disease and the proximity of other affected staff and patients, it can spread quite quickly through hospitals, nursing homes and schools.

Media interest was high throughout the operation, and despite repeated statements explaining the aetiology of the virus, it was repeatedly implied in reports that this was a 'hospital virus' and not a virus carried around in the local community and brought in and out of institutions like hospitals.

Royal Berkshire and Battle Hospitals trust forms one large district hospital with 759 beds spread across two sites. The trust has a staff of 3,662 (whole-time equivalents). There is currently a£90m consolidation programme underway to bring both hospitals to one site. There are 22 wards and departments across the whole trust, with a mixture of new and 100-year-old buildings.

The infection control team works closely with the PHLS team in the delivery of infection control and advice both across the trust and the community.

The Norwalk-like virus is responsible for outbreaks of gastro-enteritis, particularly during late winter and early spring, both in hospitals and in the community. The illness is self-limiting with symptoms ranging from nausea to vomiting and diarrhoea. Symptoms characteristically last 24-48 hours, with the affected person remaining infectious for 48 hours after the symptoms have subsided.

symptoms, including diarrhoea and vomiting. The infection control nurse visited the ward and immediately informed the infection control doctor, director of operations and other senior managers.

An outbreak meeting the following morning was attended by the chief executive, nursing and operations directors, clinical service unit managers, bed managers and lead sisters. Following the meeting, the press office, occupational health, virology department and the communicable diseases consultant were also contacted. It became apparent that the exercise needed to be led strategically and information co-ordinated across the trust. The assistant director of nursing and clinical services unit manager for surgery were asked to lead the management of the outbreak. The trust had also rewritten its major incident procedure following the opening of its new accident and emergency department the previous summer.

2The team comprised the infection control team and PHLS staff, lead sisters and managers, bed managers, consultants, a representative of the nurse bank, facilities staff, Royal Berkshire Ambulance trust and the trust's press office.

The team's aim was to gather information every day and make rapid decisions which could be quickly disseminated across the trust. The boardroom was established as a command centre and whiteboards were fitted to display information.

Short briefings were held every day at 10am and 4pm with a fixed agenda. Daily decisions could be made to cancel surgery if necessary. Notes from these meetings were distributed within the hour and managers were encouraged to visit their wards and departments and give regular verbal briefings to ward staff.

Within 48 hours, it became apparent that the infection was spreading rapidly and it was mainly staff becoming infected. The difficulties were compounded by bank and agency nursing staff refusing to work on affected wards in case they also succumbed to the infection. This was despite constant reassurance by the infection control team that this was a community-based virus and not a hospital-acquired infection. The patients most affected at this time were those on medical wards.

Decisions were taken to ease staffing and capacity problems. These included the cancellation of all training and education for two weeks, which increased workforce capacity by about 10 per cent, and cancelling a group of student nurses due to start on the wards as staff were considered too stretched to supervise them.We also cancelled day surgery for 50 patients so nurses from that department could be redeployed. Additionally, 1The medical lead sister contacted the infection control team on 14 October to inform them that the renal ward had six patients with similar nurses and doctors were sent out with ambulances to triage patients outside A&E, where many of the staff had been affected by the virus.Hand gel was installed by all bedsides to improve staff hygiene and unaffected wards had to be kept free of patients who were thought to have the virus - though some movement of patients was inevitable.Doctors conducted ward rounds twice a day to speed up discharges, which freed a lot of beds in the afternoon ready for patients admitted during the evening.

Though every effort was made to contain the patients and staff affected by the virus, it spread rapidly around the trust, affecting 26 wards and departments.Media interest was intense due to the number of hospitals that had already been affected and, despite best efforts to assure the public that it was safe to attend outpatient clinics, there still seemed to be a perception that the hospital was 'a dirty place'.

We discouraged visitors, especially if they had experienced diarrhoea and/or vomiting, and posters were pinned around the trust explaining this.

Daily staff bulletins were also electronically published, advising staff to report any symptoms to occupational health and to stay away until they had been symptom-free for 48 hours.

Wards were re-opened after deep cleaning once staff and patients had been symptom-free for 48 hours and no new cases reported. Official 'standdown'was on 1 November, as it was felt that the outbreak had been brought under control. By 11 November, no new cases had been reported.

The debrief meeting was conducted by the two co-ordinating managers in early December, with an invited officer from the Thames Valley strategic health authority. All staff involved were invited to return comments by e-mail on how they felt the exercise had been conducted and what lessons could be learnt.

The exercise was seen as a good example of team working across disciplines in the trust. The early identification of the outbreak and ongoing surveillance were seen as very effective. Other successes included the quick communication around the trust. There was also good communication via PHLS with primary care, which led to support from GPs, and good co-operation from Thames Valley University, which reorganised many of the post-registration courses and provided some tutors who came to work on the wards.The participation of the ambulance trust was seen as another plus point. Other factors deemed to be successful were that consultants worked well together and the facilities staff made an excellent effort in deep cleaning the wards at weekends.

Room for improvement

Denial in some areas at the beginning of the outbreak and a perception that it was being kept hidden to protect staff.

Insistence by some departments that patients from affected wards needed to be isolated, despite reassurance from the infection control team.

Lead sisters felt they could have been involved earlier.

The press office would have liked more information and a 'message of the day' bulletin to aid them in their twice-daily press briefings.Media interest was intense and the office had to turn press statements around very quickly.

E-mails were ineffective in communicating with ward staff as these were only opened by the ward clerk in the morning. It was more effective for managers to walk around and tell them.

Some staff, particularly doctors, came to work with symptoms despite all the communications from occupational health.

Clarifying whether bank staff were eligible for sick pay if they became affected.

The outbreak was brought under control by a prompt response. The early establishment of a comprehensive team facilitated strategic decisions to be made across the trust.And it eased liaison with partners like Thames Valley University, Berkshire Ambulance trust and primary care trusts.

The lessons learnt from this exercise will be transferred into the major incident procedure, and the debrief has been published for all staff to see.

Key points

An outbreak of the Norwalk-like virus at an acute hospital in October affected 147 patients and 200 staff.

It was brought under control within two weeks, following the establishment of a team to manage the incident.

Some day surgery was cancelled, but no inpatient operations were affected.

The public was discouraged from visiting the hospital during the outbreak.

Local GPs were co-operative about managing patients with the virus at home.

Some doctors came to work with symptoms, despite the trust urging affected staff to stay at home.

REFERENCES 1Chadwick et al.

Management of hospital outbreak of gastro-enteritis due to small round structured virus. Journal of Hospital Infection, 2000.

2Royal Berkshire and Battle Hospitals trust.Major incident procedure, 2002.

Alison Browne is assistant director of nursing and Adrian Dalby is clinical unit services manager for surgery Royal Berkshire and Battle trust.