Managing Norovirus Infections in Hospitals

Noroviruses are the leading cause of viral gastroenteritis, affecting an estimated 21 million people in the U.S. each year. This highly contagious virus can take a toll on a patient, producing nausea, acute-onset vomiting, watery diarrhea, abdominal cramps, and other problems. An outbreak can have a massive clinical impact, causing life-threatening complications for patients while disrupting healthcare facilities and impacting costs.

Hospitals and other facilities face three main concerns related to norovirus outbreaks:

  • Nosocomial norovirus infections may prolong hospitalizations and cause complications, such as chronic illness and death, in immunocompromised and other vulnerable patients.
  • Outbreaks can be costly if not controlled quickly. Hospitals can not only sustain additional costs for cleaning and disinfection, they also are impacted by the costs of longer hospitalizations for inpatients, postponed surgeries, staff absenteeism, and possible unit closures.
  • Noroviruses can mutate in patients with chronic infections. These people then become reservoirs where new variants develop, which perpetuates the cycle of infection.

Because norovirus infections are so common and their costs so extensive, hospitals need to work to control infections and prevent outbreaks. However, it’s virtually impossible to prevent the introduction of norovirus in the facility when you consider all possible sources. Patients, staff members, visitors, or even food brought in by visitors can all harbor the virus. So far, the only factor that reduces the likelihood of an outbreak is activating infection control measures as early as possible—even when only one or two patients experience vomiting and diarrhea.

Infection Control Measures
The Centers for Disease Control and Prevention recommend these measures to limit norovirus transmission:

• Isolation precautions and patient cohorting—Avoid exposure to vomitus and diarrhea. For patients with signs and symptoms of norovirus gastroenteritis, use contact precautions and a single occupancy room. Cohort patients in groups, such as symptomatic, asymptomatic exposed, and asymptomatic unexposed.

• Hand hygiene—Because alcohol-based products may not inactivate noroviruses, use soap and water for hand hygiene before and after contact with patients who have suspected or confirmed norovirus gastroenteritis.

• Patient transfer and ward closure—If possible, transfer patients only to facilities that can maintain contact precautions. Otherwise, postpone transfers until patients no longer need contact precautions.

• Diagnostics—If the laboratory does not perform polymerase chain reaction (PCR) assays or if assay results are delayed, use Kaplan’s criteria to identify a norovirus outbreak. Criteria include vomiting in more than half of symptomatic cases, mean incubation of 24 to 48 hours, mean duration of illness of 12 to 60 hours, and no bacterial pathogen isolated in stool cultures.

• Environmental cleaning—During an outbreak, increase unit cleaning to twice a day. Increase cleaning and disinfection of frequently touched surfaces to three times a day.

• Staff leave and policy—Follow sick leave policies for staff members who exhibit symptoms of norovirus infection. Exclude ill personnel from work for at least 48 hours after symptoms resolve. When they return to work, stress the importance of hand hygiene, especially before and after each patient contact. In an outbreak, establish protocols for staff cohorting to ensure that staff members care for one patient cohort on their ward and do not move between patient cohorts.

• Communication and notification—If an outbreak is suspected, notify appropriate local and state health departments, as required.

For practice guidelines, patient teaching handouts, and other resources related to norovirus, look into Mosby’s Nursing Consult.

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