Three Vomiting Patients on an Older-Adult Rehabilitation Ward
On a 28-bed older-adult rehabilitation ward, three patients developed vomiting and watery diarrhoea within 36 hours. The first, Mrs A (84), vomited twice on Tuesday night and had four loose stools by morning. A second patient in the adjacent bay and a third patient two bays away are now symptomatic. None has received antibiotics in the past eight weeks, none has travelled, and stool cultures from the first patient are pending. Two healthcare assistants have also reported feeling nauseated; one worked a night shift while unwell. The ward uses alcohol hand rub at every bed space; the shared assisted bathroom has one hoist and one commode. The ward manager asks you whether to close the ward to admissions and whether staff can use alcohol rub 'because there is no sink near bay 3'.
1. What is the most likely cause, and what infection prevention actions should be taken in the first hour?
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Likely cause: norovirus - sudden vomiting plus watery diarrhoea in three patients over 36 hours on a closed older-adult ward, with staff also affected. The absence of recent antibiotics makes Clostridioides difficile less likely, though it is not excluded. Send stool for culture, viral PCR and C. difficile testing, but do not wait for results.
First-hour actions:
- Isolate symptomatic patients in single rooms with en-suite toilets where possible. If not, cohort them in one bay with a dedicated toilet or commode and dedicate staff to that cohort.
- Use gloves and apron for contact, remove and dispose of them after each patient, and perform hand hygiene with soap and water.
- Clean shared equipment - hoist, commode, blood-pressure cuff - between patients with a chlorine-based product at the correct concentration for norovirus, and increase bathroom cleaning.
- Stop new admissions and transfers to the ward; inform the bed manager and infection prevention team; consider closing the ward.
- Stop communal activities, restrict visitors, especially children and food handlers, and keep a line list of patients and staff with symptom dates.
- Collect stool samples from affected patients and start precautions immediately.
- Ensure supplies: gloves, aprons, soap, paper towels, chlorine, sick bowls and designated waste bags.
Do not move symptomatic patients around the hospital unless clinically essential.
2. Why is alcohol hand rub inadequate here, and how would you manage hand hygiene when there is no sink near bay 3?
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Alcohol hand rub is not reliable against norovirus because it is a non-enveloped virus; alcohol disrupts lipid envelopes, which norovirus lacks. Soap and water physically removes the virus and is the required hand hygiene method during an outbreak, including after glove removal. The missing sink is a system problem, not a reason to use rub.
Practical solutions:
- Identify the nearest sink and set up a temporary hand-wash station with running water, liquid soap and paper towels; a portable sink or a designated sluice sink may be needed.
- If staff cannot wash hands immediately, they must not move between patients. Arrange a runner or relocate the cohort so a sink is accessible. Do not use alcohol rub as a substitute.
- Put up signage, remove hand-rub-only prompts in the affected area, and ensure soap and towels are restocked.
- Clean high-touch surfaces and toilets at least twice daily with chlorine and clean visible soiling immediately. Use a concentration appropriate for norovirus, commonly 1,000 ppm available chlorine for surfaces and stronger for vomit or faeces per local policy.
- Manage spillages with absorbent material, then disinfect, and avoid aerosol-generating cleaning that can spread virus.
Escalate the sink problem in writing to the ward manager and infection control, because it is a breach risk.
3. What advice should be given about staff exclusion, and when can the outbreak be declared over?
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Staff exclusion: healthcare workers with vomiting or diarrhoea should stay off work until 48 hours after symptoms have completely resolved. Contact the healthcare assistant who worked while unwell, advise her and record the dates; she should not return until 48 hours symptom-free. Agency and bank staff are covered by the same rule. Do not offer light duties, because norovirus spreads readily.
Ward status: keep the ward closed to new admissions and transfers until 48 hours after the last new case, or 72 hours if local policy specifies, and after a deep clean. The infection prevention team should formally declare the outbreak over; the ward manager should not reopen unilaterally.
Communication: inform the on-call manager, infection control, occupational health and the cleaning contractor. Keep a daily line list, brief all staff at handover, and give visitors clear instructions, discouraging visits if they are unwell.
Review: after the outbreak, examine hand hygiene facilities, staffing levels, cleaning audits and whether shared equipment contributed. The key learning is often that alcohol rub was relied on where soap and water were required, and that symptomatic staff felt pressured to work.