POLICY FOR THE MANAGEMENT OF PATIENTS WITH CLOSTRIDIUM DIFFICILE INFECTION

Transcription

1 POLICY FOR THE MANAGEMENT OF PATIENTS WITH CLOSTRIDIUM DIFFICILE INFECTION DOCUMENT CONTROL: Version: 3 Ratified by: Clinical Effectiveness Committee Date ratified: 9 August 2012 Name of originator/author: Senior Infection Prevention and Control Nurse Specialist Name of responsible Infection Prevention and Control Committee committee/individual: Date issued: 17 August 2012 Review date: August 2015 Target Audience The policy applies to all staff providing care to all patients under the care of the Trust, whether in a direct or indirect patient care role.

2 CONTENTS SECTION PAGE NO 1. INTRODUCTION 4 2. PURPOSE 4 3. SCOPE 4 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES Board of Directors Director of Infection Prevention and Control (DIPC) Infection Prevention and Control Committee Infection Prevention Doctor Infection Prevention and Control (IPC) Practitioner Consultant Medical Staff Modern Matrons/Service Managers Staff Chief Pharmacist 7 5. PROCEDURE/IMPLEMENTATION Definition of Clostridium Difficile Diarrhoea Clearance and Repeat Specimens Prevention of Spread Prevention of Spread in In-Patient Areas Recurrence of Symptoms Discharge Prevention of Spread in the Inpatients Own Home TRAINING IMPLICATIONS 15 7 MONITORING ARRANGEMENTS EQUALITY IMPACT ASSESSMENT SCREENING Privacy, Dignity and Respect 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS REFERENCES APPENDICES 18 Appendix 1 Bristol Stool Chart 19 Appendix 2 Stool Chart 20 Page 2 of 24

3 Appendix 3 Healthcare Associated Infection Risk Assessment 21 Form Appendix 4 Isolation Nursing Sign 22 Appendix 5 National Colour Coding Scheme for Hospital Cleaning Materials and Equipment. 23 Appendix 6 How to make up a disinfectant solution poster 24 Page 3 of 24

4 1. INTRODUCTION Clostridium difficile associated disease is often a complication of broad-spectrum antibiotic therapy; occurring when a reduction in normal intestinal bacteria/flora allows Clostridium difficile to flourish and produce toxins (A & B). Clostridium difficile is an anaerobic bacterium (able to live without oxygen) that is present in up to 3% of healthy asymptomatic adults. On exposure to oxygen Clostridium difficile forms spores, which help the bacteria survive for long periods of time within the environment. The spores are resistant to many disinfectants. Most symptomatic patients have explosive, watery, foul smelling diarrhoea and may also have abdominal pain and fever. Symptoms vary from mild diarrhoea to severe pseudo membranous colitis (inflammation of the gut) or toxic mega colon, which often become life threatening. Clostridium difficile is spread via the faecal-oral route. The bacterium produce highly resistant spores which survive for long periods in the environment and can be acquired from contact with: other infected patients the hands of health care workers the contaminated environment/equipment The primary cause of Clostridium difficile infection is antibiotic exposure. Gastro-intestinal surgery can also increase a person s risk of developing the disease. A long length of stay in healthcare settings and immuno-suppression leads to an increase in patients who are carriers of the organism. All age groups can be affected however; the elderly are most at risk. Over 80% of cases are reported in the over 65 age group. Children under the age of 2 years are not usually affected. A key measure in preventing the acquisition of Clostridium difficile infection is control of broad spectrum antibiotic usage. 2. PURPOSE The purpose of this policy is to direct staff on the management of patients who are diagnosed with Clostridium difficile positive diarrhoea in order to minimise the risk of cross infection. The policy content is based on sound infection prevention and control principles and national evidence for the management of Clostridium difficile infection. This policy should be read in conjunction with other infection prevention and control policies, particularly Hand Hygiene, Isolation, Standard Precautions, Decontamination and Linen Management. 3. SCOPE The policy applies to all staff providing care to all patients under the care of the Trust, whether in a direct or indirect patient care role. Page 4 of 24

5 Adherence to this policy is the responsibility of all staff employed by the Trust, including agency, locum and bank staff contracted by the Trust. This policy should be read in conjunction with other infection prevention and control policies, particularly Hand Hygiene, Isolation, Standard Precautions, Decontamination and Linen Management. This policy should be considered and included in services that are contracted and commissioned by the Trust. This policy applies to all staff, service users, visitors, contractors and other persons who enter Trust owned or rented buildings or grounds. It also applies to staff who visit service users in their own homes. 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Board of Directors The Board of Directors are responsible for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and/or requirements. 4.2 Director of Infection Prevention and Control (DIPC) The DIPC reports directly to the Chief Executive and the Board: any identified cases of Clostridium difficile infection reports all Clostridium difficile cases requiring root cause analysis investigation reports directly to the Chief Executive and assure the board of directors on the organisations performance in relation to HCAIs acts on legislation, national policies and guidance, ensuring effective policies are in place and audited in relation to Clostridium difficile 4.3 Infection Prevention and Control Committee The main duties of the Infection Prevention and Control Committee are: To oversee compliance with national standards/targets in relation to the prevention and control of healthcare associated infections (HCAI), including the Health and Social Care Act NHS Litigation Authority (NHSLA) the Care Quality Commission. To oversee key infection prevention & control issues in regards to Policy development and review Audit Education & training Communication with staff patients and the public Monitor infection control incidents Review root cause analysis reports, identify lessons learnt, develop and monitor action plans To ensure that robust plans for the management of outbreaks of infection are in place and to monitor their effectiveness To agree the annual infection prevention and control report and work programme prior to its submission to Clinical Governance Committee Page 5 of 24

6 To inform the Clinical Governance Committee of clinical risk issues relating to the Trust To monitor compliance for infection prevention & control training To oversee the Trust s compliance with Essential Standards of Quality and Safety (Outcome 8) To horizon scan for new guidance and documents relating to infection prevention & control To oversee the Trust s infection prevention & control work programme 4.4 Infection Control Doctors/Consultant Microbiologists These staff are medical microbiologists hosted within the provider acute Trust whose main duties are to: Be available for 24 hour access, arrangements made through local service level agreements Provide expert microbiology advice for the management and treatment of microorganisms including outbreaks of infection Advise on antibiotic policy/prescribing and challenge inappropriate practices 4.5 Infection Prevention and Control Nurse Specialists (IPCNS) These staff are employed within RDaSH. Their role is: To provide expert professional advice and education on the prevention and control of infection to other professionals, multi-disciplinary groups, patients and carers To lead in the investigation of identified cases of infection/alert organisms & conditions To advise on control measures, delegating responsibility to Trust staff as appropriate To give advice on complex issues relating to infection prevention and control and report findings to the DIPC To liaise with the Consultant Microbiologists for ribotyping if 2 or more cases of Clostridium difficile infection toxin positive are identified within the same inpatient area. 4.6 Consultant Medical Staff The Consultant Medical staff are responsible for the supervision of any Junior Medical staff assigned to work with them, and as part of this supervision they should be satisfied that the Junior staff member: Reads and understands the policy Adhere to the policy Are aware of and comply with antibiotic prescribing guidance 4.7 Modern Matrons/Service Managers All Service Managers and Modern Matrons are responsible for: Membership at the Infection Prevention and Control Committee Ongoing compliance with this policy within their clinical areas and reporting non compliance to the DIPC via the IP&CT Reporting all matters relating to infection prevention and control to the Deputy Director Page 6 of 24

7 of Nursing Facilitating feedback of information related to surveillance data and identified cases of infection/alert organisms & conditions Report confirmed cases of infection/alert organisms & conditions through the Trust s IR1 system 4.8 Staff All staff who are involved with the care of a patient within inpatient and community services must: Comply with this policy and guidance on all identified cases of Clostridium difficile infection. It is the responsibility of each individual member of staff to: Adhere to the requirements set out within this policy 4.9 Chief Pharmacist Complete pharmaceutical root cause analysis on each patient diagnosed with Clostridium difficile infection toxin positive Complete antibiotic and proton pump inhibitor prescribing audit as requested by the IP&C Team Report findings to Medicines Management Committee and Infection Prevention and Control Committee 5. PROCEDURE/IMPLEMENTATION 5.1 Definition of Clostridium difficile diarrhoea One episode of diarrhoea, defined either as stool loose enough to take the shape of the container used to sample it, or as Bristol Stool Chart type 7 (Appendix 1) that is not attributable to any other cause, including medicines, and that occurs at the same time as a positive toxin assay (with or without a positive Clostridium difficile culture) and/or endoscopic evidence of pseudo membranous colitis. 5.2 Clearance and repeat specimens Symptoms resolve no further Clostridium difficile toxin test required Symptoms persist despite treatment further Clostridium difficile testing is justified at least 4 weeks after previous test Symptoms resolve then reoccur repeat Clostridium difficile testing is only justified to diagnose relapse of the condition. There is a risk of relapse of symptoms in about 20 30% of patients. If the initial test returns a negative result, but symptoms persist consider retesting the patient especially if no other explanation can be identified for the symptoms. Formed stools will not be tested. 5.3 Prevention of Spread Page 7 of 24

8 Diagnosis Clostridium difficile should be managed as a diagnosis in its own right and clinicians should apply the mnemonic protocol SIGHT when managing suspected potentially infectious diarrhoea. S I G H T Suspect that a case may be infective where there is no clear alternative cause for diarrhoea Isolate the patient and consult with the infection prevention and control team (IPCT) while determining the cause of the diarrhoea Gloves and aprons must be used for all contacts with the patient and their environment Hand washing with soap and water must be carried out before and after each contact with the patient and the patient s environment Test the stool for toxin by sending a specimen immediately All patients with suspected potentially infectious diarrhoea must be isolated immediately. The prevention of spread will be aided by early diagnosis, therefore as soon as patients present with diarrhoea a stool sample must be obtained and sent for laboratory analysis to detect the presence of Clostridium difficile toxins. Once the diagnosis is confirmed it is not necessary to send repeat specimens unless another cause of diarrhoea is suspected. The laboratory request form must identify any antibiotics the patient has been receiving in the previous 28 days. The form must also include any relevant clinical details including the date of onset of symptoms Documentation (in all cases) Monitor, record and report potential signs of pseudo membranous colitis e.g. bloody and/or mucoid diarrhoea, abdominal distension/tenderness, hypotension, fever and tachycardia. Staff must use the Bristol Stool chart and accurately complete and maintain stool observation charts (Appendix 2) whilst the patient is symptomatic. Fluid intake and output charts may be required in addition to assist in the detection of and monitoring of dehydration. Page 8 of 24

9 Staff must ensure that the transfer/discharge section of the Healthcare Associated Infection Risk Assessment Form is completed prior to transferring/discharging the patient to another healthcare premise to inform the receiving organisation/area of any infection risks (Appendix 3). Risk Factors The risk of acquiring Clostridium difficile is significantly increased for the following patient groups: individuals > 65 years of age those whose immune system is compromised patients who have spent long periods in healthcare settings or who have had several admissions to hospital in the previous 6 months recent use of antibiotics especially broad spectrum e.g. Cephalosporins, and multiple courses recent surgery, especially gastro-intestinal surgery serious underlying disease/illness prolonged use of proton pump inhibitors Prevention A key measure in preventing the acquisition of Clostridium difficile is controlling antibiotic usage. The following guidance should be followed: Select narrow rather than broad-spectrum antibiotics Change antibiotic to narrower spectrum when organism identified Stop antibiotics if non-infective diagnosis is made Use oral agents whenever possible An appropriate medical clinician must approve non-formulary antibiotics. Advice may also be sought from a Consultant Medical Microbiologist. 5.4 Prevention of spread - In-patient areas Single Room Isolation Patients with unexplained diarrhoea should be isolated in a single room until infective causes have been excluded or no symptoms are reported for 48 hours. If isolation is not possible then the Infection Prevention and Control Team (IPCT) must be contacted, and will assist with risk assessment of the individual. If more than one patient on the ward develops unexplained diarrhoea, the IPCT must be contacted immediately for advice and support with the management of a potential outbreak of infection. An isolation notice must be placed on the door/bay informing staff and visitors of the specific requirements needed to be taken to reduce the risks of cross infection (Appendix 4) Unless it is an emergency, patients must not be moved to other wards or attend other Page 9 of 24

10 departments whilst symptomatic. Advice from the IPCT must be sought prior to transfer. An inter health care transfer form must be completed if the patients clinical condition dictates they require transfer to another healthcare organisation and the receiving hospital must be informed prior to transfer. Non urgent transfers should be postponed until the patient is asymptomatic and has remained so for 48 hours. If more than one patient on the ward develops unexplained diarrhoea, the IPCT must be informed. Out of hours, the Consultant Microbiologist must be informed. Patients with confirmed Clostridium difficile diarrhoea must be isolated in a single room, preferably one with its own toilet/en-suite facilities. Patients with Clostridium difficile diarrhoea must not be nursed in open bays/ dormitories without a thorough risk assessment due to the high risk of environmental contamination and subsequent risk of cross infection. The decision to nurse a symptomatic patient in a bay must be a last resort and the IPCT/Consultant Microbiologist must be informed as soon as possible. If the isolation room has no toilet a commode and urinal (if relevant) must be designated for that patient s use only. Bed pans and urinals must be decontaminated after every use in a mechanical washer/disinfector or pulp products may be used which are then disposed of into a macerator. Commodes must be decontaminated thoroughly after each use using Chlor-clean or other suitable antimicrobial agent as stated in the Decontamination policy. A designated toilet may only be allocated to the patient if adjacent to their room as the risk of environmental contamination is increased if patients have longer distances to travel to get to toilet facilities. The decision to cohort patients with Clostridium difficile in the event of more than one patient being affected will be made in consultation with the IPCT in order to minimise the risk of cross infection occurring. The nurse in charge of the ward will inform domestic services who will instigate enhanced cleaning measures. Hand Hygiene Staff and visitors must observe strict hand hygiene precautions before and after each patient contact or contact with the immediate environment as directed by the World Health Organisation s 5 moments for hand hygiene (2009) and according to the Trust hand hygiene policy. Hand hygiene must be performed at the point of care. Hand decontamination must be performed using liquid soap and water. Alcohol hand gel is not effective against Clostridium difficile and must not be used as an alternative to soap and water. It can be applied after washing to rid hands of other organisms. Patients must be encouraged to maintain their own personal/hand hygiene and should not have any contact with other patients or their food. Patients should be encouraged to wash their hands before meals and after using the toilet. Those who are unable to maintain their own hygiene must be assisted to clean their hands. Page 10 of 24

11 Personal Protective Equipment (PPE) Disposable gloves and aprons must be worn for all direct care of the patient or contact with their environment. After use these must be removed and disposed of immediately following the episode of care into the appropriate waste stream, as outlined in the Trust Waste Management Policy and hand washing performed. Clinical staff must also wear gloves and aprons when: disposing of excreta cleaning up body fluid spillages All staff must wear disposable gloves and aprons when decontaminating the isolation room or any equipment contained within that room. Face/eye protection should also be worn if there is an anticipated risk of splash or contamination of the mucous membranes. If visitors intend to provide direct care to the patient they will be required to wear disposable gloves and aprons. For routine social contact during visiting they are not required to wear PPE but must ensure they clean their hands thoroughly with soap and water before leaving the isolation room. Linen Must be managed as contaminated and must be disposed of into water soluble bags prior to placing in the correctly labelled laundry bin. The Trust Laundry policy must be adhered to at all times to negate risks of cross infection to staff, visitors and patients. Crockery/Cutlery No special measures are required. Equipment Keep equipment and furniture within the isolation room to a minimum. Do not keep large quantities of consumables within the isolation room. Keep stock levels to a minimum and replenish as required. Equipment must be thoroughly decontaminated after each use according to the Trust decontamination policy. All reusable equipment must be thoroughly decontaminated before being used on another patient. Guidance can be sought in the Trust decontamination policy. It is preferable to use single use/single patient use equipment for symptomatic patients e.g. BP cuffs, tourniquets etc. If this is not possible the use of designated pieces of equipment is recommended. Environmental Cleaning Page 11 of 24

12 A separate mop, bucket and colour coded (Appendix 5) cleaning equipment must be used for the isolation area. Particular attention should be paid to all patient contact areas such as tables, chairs, horizontal surfaces, door handles etc Toilet seats must be thoroughly cleaned with Chlor-clean or other approved antimicrobial agent (Appendix 6) regularly. The person in charge must inform the domestic team on a daily basis which rooms need to be cleaned. The environment must be cleaned twice a day using either: A two stage clean: Decontamination with neutral detergent and water/detergent wipe, followed by hypochlorite solution 1000ppm (e.g.haztabs) Or A one stage clean (combines the two stages together): Decontamination with an antimicrobial disinfectant (e.g. Chlor-clean) Equipment should be cleaned as above but manufacturers guidance must be taken into consideration. The use of antimicrobial wipes eg: Tuffie 5 wipes may be used to decontaminate equipment that cannot be saturated with water (electrical equipment). Terminal Cleans Must be performed: When the patient has been symptom free (passing formed stool 1-4 on Bristol Scale) for more than 48 hours even if the patient is to remain in the side room On the transfer, discharge or death of a patient All equipment/consumables that cannot be decontaminated must be discarded in accordance with Trust Waste Management policy. All reusable equipment and furniture in the room must be decontaminated according to Trust Decontamination policy. Curtains must be taken down and treated as contaminated linen for laundering. Blinds must be laundered/ cleaned according to manufacturers instructions. If the room has a carpet it must be shampooed and then steam cleaned. All clinical areas should be regularly assessed for cleanliness and results fed back to clinical teams, cleaning teams and the Matron/Manager. Areas of concerns should be addressed immediately. Waste Treat waste as hazardous whilst patient is symptomatic. Please refer to the Trust s Waste Management Policy. Page 12 of 24

13 Treatment If antibiotics are required an appropriate Medical Clinician must approve them. Advice should also be sought from a Consultant Medical Microbiologist. Anti - motility drugs e.g. Loperamide should be avoided, as this makes is difficult for the toxins to be dispelled. Fluid replacement therapy may be necessary and blood tests for urea and electrolytes will be required to monitor rehydration procedures. 5.5 Recurrence of symptoms Reoccurrence of symptoms is common occurring in approximately 20% of cases Regard the patient as being infectious. Re-commence appropriate infection prevention and control precautions including isolation into a single room. Inform the IPCT. Ask clinicians to review the patient in regards to antibiotic therapy. 5.6 Discharge If a patient is being discharged to another healthcare facility (i.e. Care Home, hospital) or will be receiving healthcare services at home, it is important to communicate full clinical details during discharge planning. Patients should only be discharged to a residential setting when they have been asymptomatic for at least 48 hours. Patients can be discharged in to their own home if they still have diarrhoea but must be improving. A Healthcare Associated Infection Risk Assessment Form must be completed and sent with the discharge summary. (Appendix 3). All patients identified as being toxin positive Clostridium difficile infection must be given a Clostridium difficile information leaflet and card. The card informs other healthcare providers that the patient has been identified as having Clostridium difficile infection (Toxin positive) and care should be taken if the patient needs further antibiotic therapy. If the patient is an inpatient the staff will provide a leaflet and card from the Infection Prevention and Control Nurse Specialists to explain/give to the patient. 5.7 Prevention of spread in the patient s own home advice for community staff If asymptomatic no special measures are required. If symptomatic: Monitor Page 13 of 24

14 Ask patient or household members/ family/carers to keep a diary of bowel frequency and type of stool Observe for signs of dehydration encourage good oral intake Monitor for signs of pseudomembranous colitis e.g. passing blood, abdominal distension/tenderness, hypotension, fever, and tachycardia Hospital admission should be considered if diarrhoea worsens, there are signs of colitis or dehydration or the family are not coping at home Report any concerns to the patient s General Practitioner/Consultant. Treatment Send initial stool sample to confirm diagnosis no further specimens are required unless a different organism is suspected. Review current antibiotics and stop if possible. Hospital admission should be considered if diarrhoea worsens and if intravenous hydration is required. Standard Precautions Supplies of gloves, aprons and incontinence pads will be required for family/carers/community staff. Waste should be disposed of in the hazardous waste stream whilst patient is symptomatic. Hand Decontamination: Household members, visitors and community staff must wash their hands with liquid soap and water after contact with the patient, their bedding, clothing and equipment. Community staff may use soapy hand wipes as an alternative. Household members must be encouraged to wash their hands before and after preparing or serving food The patient must be encouraged to wash their hands especially after using the toilet and before meals. The importance of hand hygiene must be discussed with the patient if appropriate to do so. Alcohol hand gel is not effective against Clostridium difficile. Advice for Patients/Relatives on Dealing with Contaminated Linen in the Patient s Home In the patient s own home the washing machine/washing area may be in the kitchen. This in itself may present some risks. Therefore to minimise risks the following actions should be taken: If contaminated linen needs to be washed, this should be avoided whilst food is being prepared. Soiled or infected linen should be washed separately, after all other laundry, using the hottest wash possible for the fabric. Use of the sluice or pre-wash programme is recommended. Handling of the linen should be kept to a minimum. Overloading of the machine should be avoided. Page 14 of 24

15 Hand washing or manual sluicing of linen is not recommended, however, where soiled or infected clothing is washed by hand, it is preferable to wash the clothing/linen in a designated bucket/bowl which can be cleaned after use and disinfected using a chlorine/bleach solution. Disposable gloves are recommended to avoid contact with contaminated clothing or bedding. Hands should be washed thoroughly after contact with dirty linen and after removing gloves. Cleaning Use household detergent and hot water with a disposable cloth. Discard the cloth after each activity. Toilet flush handles, hand basin taps and toilet door handles should be cleaned daily or if contaminated with faeces. Toilet seats should be cleaned after use. The toilet should be cleaned daily with a sanitizer e.g. bleach based household cleaner. Bedpans, commodes and urinals should be emptied down the toilet, washed with household detergent and hot water and then dried. Advice for patients attending Day Services/Out Patient Clinics Patients who are symptomatic or who have not been asymptomatic for >48 hours must refrain from attending any Day Care Services or Out Patient Clinics to prevent the spread of infection. Patients who develop diarrhoeal symptoms whilst attending these areas should be sent home promptly. Information Leaflet and Card Patients diagnosed with Clostridium difficile infection toxin positive in the community are usually managed by their General Practitioner and the information leaflet and card should be provided by the General Practitioner. 6. TRAINING IMPLICATIONS There are no specific training needs in relation to this policy, but all staff will need to be aware of its contents. Staff will be made aware through: Line manager Team Brief Team meetings One to one meetings/supervision Trust Policy web site 7. MONITORING ARRANGEMENTS Page 15 of 24

16 Area for Monitoring How Who by Reported to Frequency Breaches of Policy Incident reporting & RCA Modern Matron and Infection Prevention and Control Nurse Specialists Infection Prevention and Control Committee As cases occur 8 EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. Indicate how this will be met No issues have been identified in relation to this policy. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). Page 16 of 24

17 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS Hand Hygiene Policy Laundry Policy Isolation Policy Decontamination Policy Standard Infection Prevention and Control Precautions Policy Last Offices for a Patient with a Transmissible Infection Policy Policy For The Management Of Blood And Body Fluid Spillages Policy for the Collection, Handling And Transportation Of Pathology Specimens 10. REFERENCES Bartlett, J.G (2002) Antibiotic Associated Diarrhoea New England Journal of Medicine 346: DH/PHLS (1994) The Prevention and Management of Clostridium Difficile Infection A Report by the Joint DH/PHLS Working Group Jenkins, L. et al (2001) Infection Control Audit of Clostridium Difficile Associated Diarrhoea at the University Hospital of Wales British Journal of Infection Control Vol 3, Issue 6 Morris, M et al (2002) Clostridium Difficile Colitis: an Increasingly Aggressive latrogenis Disease? Arch Surgery 137: Department of Health (2004) Standards for Better Health. London Department of Health (2005) A Health Technical Memorandum: Safe Management of Healthcare Waste. London. Crown Copyright Department of Health (2008) The Health and Social Care Act: Code of practice for the NHS on the prevention and control of healthcare associated infections and related guidance. London. Crown Copyright. Department of Health (2006) Essential Steps to Safe, Clean Care. London. Crown Copyright. Department of Health (2007b) Saving Lives: Reducing infection, delivering clean and safe care. High Impact Intervention No. 7 Care bundle to reduce the risk from Clostridium Difficile. London. Crown Copyright. Department of Health (2007d) Saving Lives: Reducing infection, delivering clean and safe care Antimicrobial prescribing. London. Crown Copyright Department of Health (2007e) Saving Lives: Isolating patients with healthcare-associated infection. London. Crown Copyright Page 17 of 24

18 Department of Health (2008) Changes to the mandatory healthcare associated infection surveillance system for Clostridium Difficile infection, Chief Medical Officer/Chief Nursing Office Department of Health (2008b) Clean, Safe Care: Reducing infections and saving lives. London. Crown Copyright Healthcare Commission (2007) Investigation in to outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells NHS Trust. London. October Healthcare Commission (2009) Investigation into Mid Staffordshire NHS Foundation Trust. Commission for Healthcare Audit and Inspection. ISBN: Health Protection Agency (2009) Clostridium Difficile infection: How to deal with the problem. National Institute for Health and Clinical Excellence (2012) Prevention and control of healthcare associated infections in primary and community care. NICE clinical guideline 139 NHS North of England (2012) Clostridium difficile Initiative World Health Organisation (2009) Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge. Clean Care Is Safer Care. ISBN-10: APPENDICES Page 18 of 24

19 Appendix 1 Page 19 of 24

20 Appendix 2 Stool Chart Patient Name: Hospital/NHS Number Date Time Colour Type (Bristol Stool Chart) Amount (large/ medium/ small) Blood/Mucous present Page 20 of 24

21 Page 21 of 24 Appendix 3

22 Appendix 4 STOP AND THINK! Isolation Nursing All Visitors: Please wash and dry your hands before entering and on exiting the room Please ask the nurse before entering so that she/he can explain any precautions you need to take Please close the door behind you Please ask the nurse/matron or member of the infection control team to explain anything you are unsure of All Staff Please adhere to standard infection prevention and control precautions at all times Please check care plan/ward guidance if you are unsure about any infection control procedure Page 22 of 24

23 Page 23 of 24 Appendix 5

24 Page 24 of 24 Appendix 6