III. Implementation and Audit

Prioritization of Recommendations

Category I recommendations in this guideline are all considered strong recommendations and should be implemented. If it is not feasible to implement all of these recommendations concurrently, e.g., due to differences in facility characteristics such as nursing homes and other non-hospital settings, priority should be given to the recommendations below. A limited number of Category II recommendations are included, and while these currently are limited by the strength of the available evidence, they are considered key activities in preventing further transmission of norovirus in healthcare settings.

Patient Cohorting and Isolation Precautions

1. Avoid exposure to vomitus or diarrhea. Place patients on Contact Precautions in a single occupancy room if they present with symptoms consistent with norovirus gastroenteritis. (Category IB) (Key Question 1.A.1)

Hand Hygiene

8. During outbreaks, use soap and water for hand hygiene after providing care or having contact with patients suspected or confirmed with norovirus gastroenteritis. (Category IB) (Key Question 3.C.1.b)

Patient Transfer and Ward Closure

11. Consider limiting transfers to those for which the receiving facility is able to maintain Contact Precautions; otherwise, it may be prudent to postpone transfers until patients no longer require Contact Precautions. During outbreaks, medically suitable individuals recovering from norovirus gastroenteritis can be discharged to their place of residence. (Category II) (Key Question 3.C.11)

Diagnostics

17. In the absence of clinical laboratory diagnostics or in the case of delay in obtaining laboratory results, use Kaplan's clinical and epidemiologic criteria to identify a norovirus gastroenteritis outbreak. (Category IA) (Key Question 2.A.1)

Environmental Cleaning

28. Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis (e.g., consider increasing ward/unit level cleaning to twice daily to maintain cleanliness, with frequently touched surfaces cleaned and disinfected three times daily using EPA-approved products for healthcare settings). (Category IB) (Key Question 3.C.12.b.1)

Staff Leave and Policy

42. Develop and adhere to sick leave policies for healthcare personnel who have symptoms consistent with norovirus infection. (Category IB) (Key Question 3.C.3)

a. Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Once personnel return to work, the importance of performing frequent hand hygiene should be reinforced, especially before and after each patient contact. (Category IB) (Key Question 3.C.3.a)

43. Establish protocols for staff cohorting in the event of an outbreak of norovirus gastroenteritis. Ensure staff care for one patient cohort on their ward and do not move between patient cohorts (e.g., patient cohorts may include symptomatic, asymptomatic exposed, or asymptomatic unexposed patient groups). (Category IB)(Key Question 3.C.5.a)

Communication and Notification

51. As with all outbreaks, notify appropriate local and state health departments, as required by state and local public health regulations, if an outbreak of norovirus gastroenteritis is suspected. (Category IC) (Key Question 3.C.9.b)

Performance Measures for Health Departments

Use of performance measures may assist individual healthcare facilities, as well as local and state health departments to recognize increasing and peak activities of norovirus infection, and may allow for prevention and awareness efforts to be implemented rapidly or as disease incidence escalates. Evaluate fluctuations in the incidence of norovirus in healthcare settings using the National Outbreak Reporting System (NORS) [Current version of this document may differ from original.]. This system monitors the reporting of waterborne, foodborne, enteric person-to-person, and animal contact-associated disease outbreaks to CDC by state and territorial public health agencies. This surveillance program was previously used only for reporting foodborne disease outbreaks, but it has now expanded to include all enteric outbreaks, regardless of mode of transmission. Additionally, CDC is currently implementing a national surveillance system (CaliciNet) for genetic sequences of noroviruses; this system may also be used to measure changes in the epidemiology of healthcare-associated norovirus infections.