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1 Title Guideline reference number Aim and purpose of clinical document Infection Control Policy for the Prevention and Management of Primary Care Acquired Clostridium difficile Associated Diarrhoea. 008 To provide guidance about the management and control of Closridium Difficile within the intermediate care, prison health and community. Author Type New document Reviewed document Review Date February 2014 Person/group accountable for review Type of Evidence base used Issue date March 2011 C: Evidence which includes published and/or unpublished studies and expert opinion Authorised by Clinical Policies Group March 2011 (Virtual Group) / Re-authorised at meeting on 13/4/12 Impact Assessment Undertaken Yes date when Evidence undertaken collated 03/2011 No March 2011 Page 1 of 31

2 Version Control Version: 3 Ratified by: Clinical Policies Group Name of originator/author Approving body/committee: Clinical Policies Group Date issued: March 2011 Review date: February 2014 Target audience: Name of lead Director/ Managing Director Changes / Alterations made to previous version: LCH Staff & Clinical staff within Nursing & Residential Homes HMP Liverpool, Bernie Cuthel Typographical corrections. Amendments to contents page numbering Amendments to authors title in footer & header notes Section or pages amended. Page 6,8,9,10,12,13,14,16,17 removal of intranet links. Removed - Note: Priorities for HMP staff are present with the roles under the titles; registered nurse, ward manager, prescribers and service manager. Key individuals involved in developing the document Name Sheila Bowyer Jeannette Fox Designation Infection Control Matron In Patient Matron This document was circulated to the following individuals for consultation Name Members of Clinical Policies Group Designation Governance Group This document should be read in conjunction with the following documents: LCH Infection Control Policies March 2011 Page 2 of 31

3 Content Section Page Number 1 Introduction Status Purpose Scope 4 2 General Policy Statement 5 3 Definitions 6 4 Duties and Responsibilities 6 5 Process and Documentation Process Clinical Features & Risk Factors Risk Factors SIGHT Protocol Clinical Management Roles and Responsibilities 12 6 Training Requirements 16 7 Implementation, Monitoring, Review 16 8 Impact Assessment 17 9 Linked areas/information Legislation/Statutory Requirements References List of Appendices 18 Appendix 1 C.diff Assessment 19 Appendix 2 Bristol Stool Chart 21 Appendix 3 Patient Information Leaflet 22 Appendix 4 Screening Tool (Patient Care Checklist) 24 Appendix 5 C.diff Care Plan 25 Appendix 6 Care Bundle High Impact No 7 inc. Audit 28 Appendix 7 Treatment 30 March 2011 Page 3 of 31

4 1. Introduction Clostridium Difficile is a spore forming bacteria that is found in the large intestine in approximately 5% of the population. It can cause illness when the balance of the normal gut flora is disturbed by the frequent use of certain antibiotics, e.g. cephalosporin. The antibiotics disturb the balance of bacteria in the large bowel which enables the Clostridium Difficile bacteria to proliferate. (DH 2009) Once established the bacteria produces toxins, which are responsible for Clostridium Difficile associated Diarrhoea (CDAD) and which damage the cells lining the bowel. In the majority of patients the illness is mild and full recovery is usual. However, occasionally and particularly in elderly patients, it may result in serious illness and even death. (DH 2009) Clostridium Difficile has the potential to cause large outbreaks in healthcare settings if not managed appropriately via standard precautions and isolation. The devastating illness from clostridium causes a great economic burden as it causes complications and prolonged hospital stays (DH 2009) 1.1 Status This is a clinical policy document for use in Liverpool Community Health NHS Trust (LCH) 1.2 Purpose The purpose of this policy is to prevent Clostridium Difficile infection (CDI); both isolated cases and transmission leading to a potential outbreak. 1.3 Scope This policy applies to healthcare personnel working within LCH. It also applies to private contractors working on Trust premises including, locum, agency staff and volunteers. Although this policy provides specific guidance for patients in the LCH Inpatient units with relevance to staff roles and responsibilities (see section 5), it underpins the needs of patients in the community and its clinical guidance extends to staff nursing patients in their homes and in care homes. 2. General Policy Statement: LCH has developed this policy to fulfil the requirements of patients / service users receiving care from staff employed by LCH. LCH is committed to ensuring that all staff are trained and equipped to perform their role effectively. Liverpool Community Health will identify Clostridium Difficile infection in symptomatic patients and will provide quality and consistency in the delivery of clinical care when caring for an individual with known or suspected CDAD. March 2011 Page 4 of 31

5 All staff working for or on behalf of LCH will provide care, management and control CDI within the healthcare setting and community in accordance with the latest research based evidence. 3. Definitions Based on current health care policy; DH Saving Lives; Delivering clean and safe care, National Patient Safety Agency C. Difficile Infection (CDI) One episode of diarrhoea, defined either as stool loose enough to take the shape of a container used to sample it or as Bristol Stool Chart types 5 7 (Appendix 1), that is not attributable to any other cause, and that occurs at the same time as a positive Clostridium Difficile toxin assay and/or endoscopic evidence of pseudo membranous colitis (PMC). A period of increased incidence (PII) of CDI An outbreak of C. Difficile infection Clostridium Difficile Associated Diarrhoea - CDAD Personal Protective Equipment (PPE) Bristol Stool Chart SIGHT Toxin 027 Care Bundle Two or more new cases (occurring >48 hours post admission, not relapses) in a 28-day period on a ward Two or more cases caused by the same strain related in time and place over a defined period that is based on the date of onset of the first case. Diarrhoea caused by a proliferation of the bacterium Clostridium Difficile within the bowel and associated toxin production damaging the cells lining the bowel. Protective clothing, masks designed to protect the wearer s body for job-related occupational safety and health purposes, from injury - For the purpose of this document, aprons and gloves protect injury from infection. A medical aid designed to classify faeces into seven groups. The form of stool depends on the time it spends in the colon. This scale is useful to determine the condition of the colon. It is a generic indicator; it is not an absolute diagnostic tool. It is, however, a good indicator of what action is needed An acronym used by health care Trusts for patients with diarrhoea A strain of toxin produced by an organism, which causes clostridium. A grouping together of key elements of care for March 2011 Page 5 of 31

6 procedures and the management of a specific diagnosis (for the purpose of this document Clostridium Difficile) Root Cause Analysis (RCA) Infection Control & Prevention Team (IC&PT) A structured approach to investigating an infection control incident from an initial understanding of the legal and factual context, through a detailed analysis of the issues and evidence, to production of the formal report Specialist team who investigate and manage demonstrated or suspected infection/spread of infection within a particular health care setting Multidisciplinary Team (MDT) UCD A group of professionals who work together to help plan and carry out treatment for patients Unplanned care direct, telephone response team who facilitate admission to intermediate care. 4. Duties and Responsibilities The following statutory general (statutory) duties apply: All LCH staff are responsible for co-operating with the development and implementation of organisational policies as part of their normal duties and responsibilities. All other personnel will be expected to comply with the requirements of all relevant LCH applicable to their area of operation. All potential adverse incidents should be reported in line with LCH Risk Management Policies available via Trust intranet. 5. Process and Documentation 5.1 The process and documentation begins with the presentation of diarrhoea and staff s knowledge of the clinical features and risk factors of Clostridium difficile. At the point when all patients are admitted to the organisations inpatient units, these patients will be screened. (See section 5) It follows that staff are directed through the process of managing the patient symptomatic with diarrhoea and suspected/confirmed Clostridium Difficile, using the following 3 streamlined approach: 1. Mnemonic protocol (SIGHT) (table 1), which describes a sequence of activities that clinicians (doctors and nurses should March 2011 Page 6 of 31

7 apply used to practically manage potentially infectious diarrhoea in patients in the community setting and in-patient. (DH 2009) 2. Pharmacotherapy which is described using a severity grading table (appendices) 3 Roles and Responsibilities of staff. 5.2 Clinical Features Toxins produced by Clostridium difficile damage the large bowel causing watery, explosive, foul-smelling diarrhoea, which can range from mild to severe. Diarrhoeal stools are typically defined as those that take the shape of their container i.e. Bristol Stool Chart, Type 6-7(see appendix 2). Stool may be green in colour and have a distinctive smell. Fever, loss of appetite, nausea and abdominal pain/tenderness may also be present. Some patients may develop severe pseudo membranous colitis with ulceration of the colon, toxic mega colon, perforation or peritonitis, all of which may result in death. Some subtypes (notably 027) produce more toxins than others. These strains can cause more severe disease and appear to have a higher mortality (DoH, 2006). 5.3 Risk Factors Risk factors for Clostridium difficile infections include the following: Elderly (over 65 years) Long length of stay in healthcare settings Recent use of antibiotics especially broad spectrum e.g. cephalosporin s, which are harmful to normal gut flora Recent surgery, especially gastro-intestinal surgery Serious underlying disease/illness Immune compromising conditions Prolonged use of proton pump inhibitors 5.4 Mnemonic Protocol [SIGHT]] (acronym used by health care Trusts for patients with diarrhoea) The following scenarios contain wide ranging risk management procedures. See throughout this section, how table 1 is to be implemented: March 2011 Page 7 of 31

8 Table 1 S Suspect that a case may be infective when there is no clear alternative cause for the diarrhoea. I Isolate the patient and consult with the infection control team while determining the cause of the diarrhoea G Gloves and aprons must be used for all contacts with the patient and their environment H Hand washing with soap and water should be carried out before and after each contact with the patient and the patient s environment T Test the stool for toxin by sending a specimen immediately S = suspect 1. Suspect that a case may be infective when there is no clear alternative cause for the diarrhoea I = Isolation 1. Isolate the patient and consult with the infection control team while determining the cause of the diarrhoea 2. Patients in whom the cause of diarrhoea has not been determined should be isolated in a single room with a toilet or commode facilities within the room. See Isolation Policy available on intranet. 3. All patients with known CDAD must be isolated in single-room or cohorted in the case of an outbreak. 4. If a large outbreak of diarrhoea occurs within a care establishment where there are an insufficient number of single rooms for every affected patient, then the ward should be immediately closed to admissions on the advice of the Infection Control team. 5. The door of the isolation room must remain shut to prevent contamination of the shared environment. A clear door notice must be used indicating the precautions to be taken for staff and visitors. 6. A risk assessment must be carried out and documented if an infected patient is not able to be isolated due to an increased level of risk e.g. falls. March 2011 Page 8 of 31

9 7. The infection control team must also be informed. Specific precautions must be planned to reduce the risk of transmission. 8. If there is an outbreak or if cases exceed the isolation room capacity then a cohort bay or isolation ward would be required. 9 Inform the patient of progress. 10 Ensure the patient has an information leaflet. (see appendices) G = Gloves and aprons (NB This section includes a sub-section on environment) 1. Gloves and aprons must be used for all contacts with the patient and their environment 2. Personal protective equipment (PPE) including gloves and aprons, must be worn by all staff caring for patients who are symptomatic. Visitors entering the room must wear PPE. 3 Non- sterile, PPE is needed when in contact with the patient or their immediate environment or equipment is anticipated. PPE should be put on when entering the isolation room and worn during care. 4. Used items must be disposed of inside the room. Gloves should be removed first followed by the apron pulling from the back and then folding in from the inside to minimise contamination. 5. Hands must be cleansed again immediately outside the room. See PPE policy available on intranet. 6. Because of the risk of transmission, accompany the above with the following environmental measures: 7: Environment: (Sub-section) (1) Linen: 1.1 Soiled linen should be handled with the minimum agitation and disposed of in a laundry bag. The linen must be treated as infectious and secured in red alginate and then linen bags. In a nursing or residential setting where alginate bags may not be available ensure that the laundry is double bagged. In all cases only sealed laundry bags must be passed out from the room. 1.2 Patients clothing if washed at the laundry, should be washed separately and on the hottest wash the materials can stand with a sluice cycle (2) Waste management: March 2011 Page 9 of 31

10 2.1 All waste must be disposed of within the clinical waste stream within the room. 2.2 All bags must be secured prior to removal from the room. (3) Cleaning 3.1 A thorough environmental clean must be performed at least daily. Single-use disposable cloths and disposable mop heads must be used and changed immediately after use. 3.2 A general purpose detergent e.g. Hospec followed by chlorine based agent should be used. If Chlorclean or Actichlor plus is in used then this product may be used alone as it contains both detergent chlorine releasing agents. For soft furnishings and areas that cannot be cleaned with a chlorine based agent, clean with detergent and hot water and ensure it is dried thoroughly. 3.3 All surfaces, horizontal and hand touch must be cleaned three to four times a day. 3.4 Toilets, commodes and bathroom areas must be cleaned after use with a detergent followed by a chlorine based agent 3.5 Ensure that the national colour coding system is adhered to with yellow equipment used for isolation rooms. 3.6 All unnecessary items should be removed from the isolation room or ward to allow ease of cleaning. (4) Deep clean. 4.1 On discharge / transfer or when the patient has been symptom free for 48 hours the room requires a deep clean. 4.2 Nursing staff must clear the room of all patient items and linen, destroy any non- reusable equipment and decontaminate all reusable patient equipment, prior to storage or use by another patient. 4.3 Domestic staff must remove the curtains and clean all surfaces, walls, equipment and furniture with a general purpose detergent and thoroughly dried and disinfected with a chlorine based agent. (Chlorclean or Actichlor plus if available). 4.4 The curtains can then be replaced. The room and equipment may also have Hydrogen peroxide vapour (HPV) available for use H = Hand Hygiene March 2011 Page 10 of 31

11 1. Hand washing with soap and water should be carried out before and after each contact with the patient and the patient s environment. NB Alcohol hand gels are not effective as the spores are not destroyed by alcohol See Hand Hygiene Policy 2. Staff, patients and visitors must all wash their hands with soap and water in accordance with LCH hand hygiene policy. Hands must be washed when leaving the isolation room and after protective equipment has been removed T = Test the stool for toxin 1. Test the stool for toxin, by sending a specimen immediately 2. When a patient presents with diarrhoea, consider that there may be an infectious cause. 3. Confirmation of Clostridium difficile infection is via the laboratory detection of Clostridium difficile Toxins A and/ or B in stool samples. 4. When sending stool specimens to the laboratory where non specific infective diarrhoea is suspected, the specimen request form should request culture and sensitivity along with a specific C. difficile investigation. Any recent antibiotic history, frequency of diarrhoea, stool type e.g. Type 7, date of onset of diarrhoea must be included. See Specimen Policy 5. Bristol Stool chart (see appendices) should be used to determine the condition, e.g. to identify diarrhoea. The diarrhoea sample should comply with Type 7 of the Scale; otherwise the sample will not be tested for C.difficile (see appendices) 6. Only one specimen needs to be sent to the laboratory for confirmation of diagnosis, if the specimen is negative and the patient remains symptomatic (with a strong suspicion of C. difficile is the likely cause) a repeat sample should be taken. 7. Repeat stool specimens are not needed whilst a patient is symptomatic or when the diarrhoea has ceased. Retesting for C. difficile toxin (CDT) is not required in positive cases, if patients are still symptomatic within a period of 28 days. If symptoms resolve and recur after 28 days there is a need to confirm recurrent CDI further sampling may be required. 5.5 Clinical Management Goals: 1. Improvement of the patient's clinical condition (DH 2007) 2. Prevention of spread of C. difficile infection to other patients. (SIGHT) 3. Prevention of deterioration in condition Treatment Guidelines; March 2011 Page 11 of 31

12 1. Prescribing of Antimicrobials in Primary Care, must be in accordance with Antimicrobial Guide and Management of Common Infections in Primary care, which is issued to prescribers within the Provider Trust and are updated yearly. Copies can be obtained from: Medicines Management or Non- Medical Prescribing administrator All CDI patients must be assessed daily by the relevant multidisciplinary team to ensure that the infection is appropriately treated and the patient receives all the necessary supportive care. See clinical guidance tool (appendices) and roles and responsibilities (section 5) Discharge: 1 Patients should only be discharged to residential settings when their stool has returned to normal and the risk of relapse assessed. 2 If the patient still has diarrhoea, which is considered due to non-infective causes, an Infection Control Risk Assessment prior to transfer must be undertaken by the. 3 Where patients are discharged to their own home the possibility of symptoms recurring should be discussed with the patient and/or carer. 4 The patients GP and the residential home, where relevant, should be informed that the patient has been Clostridium Difficile positive during their in patient stay. 5.6 Roles and Responsibilities The roles and responsibilities of staff within LCH are as follows: Community Assessment Team 1. It is the responsibility of the health care professional who is assessing the patient to find out if the patient may be carrying an infection before being admitted to the in-patient unit. 2. It is the responsibility of the health care professional to inform the UCD professional of any infection control issue relative to the patient or changes in their condition that may affect responsive care on arrival to the in-patient units UCD 1. It is the responsibility of the UCD health care professional to facilitate an admission communicating any infection issues, about the said patient to inpatient units Registered Nurse (Kent Lodge/CCAU/HMP) 1. It is the responsibility of the registered nurse to effectively manage and safeguard the admission in relation to C diff risk assessment tool and instigate the C Difficile check list for each patient. (See appendices) (Standards of March 2011 Page 12 of 31

13 conduct, performance and ethics for nurses and midwives. Nursing and Midwifery Council, May 2008). 2. It is the responsibility of the registered nurse to ensure an effective risk assessment has been completed and that the necessary actions according to the mnemonic protocol SIGHT is followed during the admission. 3. It is the responsibility of the registered nurse, if a decision is made to screen the patient for C Difficile, to gain consent from the patient, (discussing with relatives if appropriate) explaining the reasons for the requirement of the stool specimens. See Consent to Treatment Policy 4. It is the responsibility of the registered nurse to ensure that the patient (and/or relatives) receives an explanatory leaflet. (See appendices for information for patients) 5. It is the responsibility of the registered nurse to access Language Line: Telephone number for those patients who do not speak English. Interpreters are provided between the service user and health professionals: It can be used in an emergency to deal with an immediate communication difficulty. The service is available 365 days a year covering over 120 languages. See Communication Policy 6. It is the responsibility of the registered nurse to ensure that the severity of CDI is assessed each day (see guidance in appendices) 7. It is the responsibility of the registered nurse to inform the nurse in charge of all patients found to have acquired CDI in the in-patient areas. 8 It is the responsibility of the registered nurse to complete an incident report for all patients found to have acquired CDI in the in-patient areas. 9. It is the responsibility of the registered nurse, from the results of screening, to ensure effective responsive care. 10 It is the responsibility of the nurse who is a prescriber to undertake the duties outlined in the prescriber s section (below) 11 It is the responsibility of the registered nurse who is on duty acting as the ward manager, i.e. nurse in charge, to ensure the duties of the ward manager as described below Prescribers: (i.e. medical officers, pharmacists, nurses) It is the responsibility of prescribers to 1. ENSURE THAT ANTI MOTILITY AGENTS ARE NOT PRESCRIBED FOR SYMPTOMATIC PATIENTS. Refer to British National Formulary and Antimicrobial Guide and Management of Common Infections in Primary care (current edition) March 2011 Page 13 of 31

14 1. Prescribe narrow spectrum antibiotics whenever the causative pathogen is known. 2. Review of "blind" empirical antibiotic therapy as soon as the causative pathogen has been identified. 3. Use antibiotics prudently as an essential component of controlling C Difficile infection and must only be prescribed when there is clinical evidence of bacterial infection. (Regional Drug and Therapeutics Centre, 2009) 4. Avoid the use of antibiotic "cocktails". 6. Discontinue antibiotics as soon as possible Ward Manager (Kent Lodge/CCAU/HMP) 1. It is the responsibility of the ward manager to ensure that ward staff are aware of this policy and that the work practices and training are in line with the policy as described. 2. It is the responsibility of the ward manager to ensure that all patients receive an effective risk assessment and necessary actions required prior to and during the admission for a patient suspected of CDAD. 3. It is the responsibility of the ward managers, in liaison with the infection control team, to inform senior officers within the LCH provider services of the progress throughout any outbreak. 4 It is the responsibility of the ward manager to report on the number of patients with Clostridium Difficile 5. It is the responsibility of the ward manager, if an outbreak of Clostridium Difficile results in the closure of a ward then the nurse in charge must escalate this and report it as per the LCH provider s incident reporting policy. 7. It is the responsibility of the ward manager to complete a root cause analysis within 5 days of a patient acquiring CDT on Kent/Lodge/CCAU. 8. It is the responsibility of the ward manager to ensure that all health care staff involved in the risk assessment and stool collection are trained and demonstrate competence. 9. It is the responsibility of the ward manager to ensure that each ward staff member s performance of infection control is appraised at staff reviews. 10. It is the responsibility of the ward manager, in the absence of the Matron, to ensure the Matron s duties It is the responsibility of the to work with all health care professionals to provide timely information affecting the treatment for C diff, changes in patients conditions and movement that may affect the scope of risk. (See roles and responsibilities) March 2011 Page 14 of 31

15 2. It is the responsibility of the to collaborate with all groups of staff to ensure incorporation of standards into infection control planning. 3. It is the responsibility of the infection Prevention & Control team to monitor the situation of any outbreaks with daily updates on the management of the outbreak until it is satisfactorily resolved and a full post event report will be produced. 4. It is the responsibility of the infection control team to facilitate surveillance and a full Root Cause Analysis, which must be completed on all patients who have had serious complications / death due to CDI whether previously known or new acquisitions within inpatient areas, inc HMP, residential or nursing homes or their own home Matron (Kent Lodge/CCAU) 1. It is the responsibility of the Matron to ensure the process of infection screening on the unit and that work practices are in line with this policy. 2. It is the responsibility of the Matron to ensure that resources are allocated to assure the standards outlined in this policy. 3. It is the responsibility of the Matron to ensure that the unit patient population is reviewed for complexity and diversity, ensuring the needs of the patients are met. 4. It is the responsibility of the Matron to ensure that explanation leaflets are available in other languages, where appropriate, to meet the additional needs and preferences of patients e.g. People who do not read or speak English. 5. It is the responsibility of the manager to ensure a full root cause analysis, which must be completed on all patients who have had serious complications / death due to CDI whether previously known or new acquisitions 6. It is the responsibility of the Matron to collaborate with the wider health care team to ensure incorporation of infection control standards on the unit. 7. It is the responsibility of the Matron to monitor and review this policy according to section below Service Managers 1. It is the responsibility of the Service Manager to ensure a regular review of infection control data with the wider health care team and service providers. (See section 7) 2. It is the responsibility of the Service Manager to ensure the contractors duties according to the environmental cleaning specification in this policy (SIGHT ). March 2011 Page 15 of 31

16 3. It is the responsibility of the service manager to ensure sufficient resources to ensure this policy is effective. 4. It is the responsibility of the manager to ensure a full root cause analysis, which must be completed on all patients who have had serious complications / death due to CDI whether previously known or new acquisitions within areas HMP, residential, nursing homes or own homes. 6. Training Requirements It is the responsibility of the In Patient Matron for Kent Lodge/CCAU to ensure that this cohort of staff is trained and Infection Control Matron will work with HMP Liverpool to ensure that training is undertaken as follows: 6.1. All clinical and non clinical staff attends three yearly infection control training. This training is delivered in house by the Infection Prevention & Control Team. All staff will have training logged on LCH data-base via the Learning and Development Bureau All healthcare staff undergoes risk assessment training, which is initially undertaken on induction and further as mandatory training and accident and incident reporting. 7. Implementation, Monitoring and Review 1 The Director of Operations / Executive Nurse is responsible for implementing this policy. This process has been delegated to the Infection Control Matron and the Inpatient Services Matron. 2 The Director of Operations / Executive Nurse is responsible for ensuring that this document is reviewed and if required, revised in the light of legislative guidance or organisational change. This process will be delegated to the Infection Control Matron and In-Patient Services Matron. 3. Line managers will ensure that nursing staff are aware of this policy and that the work practices are in line with the policy and guidelines as described. The monitoring process is also delegated to line managers. 4. The IP&CT will support the implementation and monitoring of audit process, provide training advice to support the RCA process. 5. The In-Patient Services Matron will support practice with a High Impact Intervention Care of CDAD Audit in compliance with this policy. (See appendices) 6. The Matrons of Infection Control and In-Patient Services will provide progress report and improvement action plans, for the organisations Clinical Quality Reviews. March 2011 Page 16 of 31

17 7. The review process should start a minimum of 3 months before the expiry of the policy and will be no longer than 3 years unless practice changes in the interim 8. Impact Assessment An impact assessment has been undertaken and retained by the author. 9. Linked areas/information LCH Infection Control Policies 10. Relevant Legislation/ Statutory requirements Health and Social Care Act List of Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 C. Diff Assessment Bristol Stool Chart Patient Information Leaflet Screening Tool (Patient care checklist) Care bundle High impact no 7 & Audit form High Impact Intervention Treatment Guidelines 12. References 1. Antimicrobial Guide and Management of Common Infections in Primary care 11th edition (Sefton) 7th edition (Liverpool, Central Lancashire and Knowsley) & incorporating Strategies to Optimise Prescribing of Antimicrobials in Primary Care. 2. British National Formulary (yearly publication) 3. Centre for Disease Control (2005) Clostridium Difficile: Information for Healthcare Providers. Updated July Department of Health (2009) Clostridium Difficile: How to deal with the problem 5. Department of Health (2006) A Simple Guide to Clostridium Difficile. DH Publications. 6. Department of Health (2007) Saving Lives: High Impact Intervention No 7 March 2011 Page 17 of 31

18 7. Department of Health (2003) Clostridium Standards Group. Report to the DH. 8. Halsey J (April 2008). "Current and future treatment modalities for Clostridium Difficile-associated disease". Am J Health Syst Pharm 65 (8): Healthcare Commission (2005) Management, Prevention and Surveillance of Clostridium Difficile. Dec. 10. Johnson, S. & Gerding, DN (2004) Clostridium Difficile. Mayhall, CG. Ed. Hospital Epidemiology and Infection Control. 3rd ed. Lippincott Williams & Wilkins. 11. Lincolnshire Care Pathway Partnership. March Mallet. J, Bailey. C (2004) Manual of Clinical Nursing Procedures. 6th edition. Royal Marsden NHS Trust. 13. Poxton, IR. (2005) Clostridium Difficile Issues Explored. The Clinical Services Journal Nov. 14 Regional Drug and Therapeutics Centre (2009) 15. The Derbyshire County PCT (2007) Infection control Team Clostridium Difficile Policy March 2011 Page 18 of 31

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21 Appendix 2 The Bristol Stool Form Scale (Bristol Stool Chart) Type 1 Type 2 Separate hard lumps, like nuts (hard to pass) Sausage-shaped but lumpy Type 3 Type 4 Type 5 Type 6 Like a sausage but with cracks on its surface Like a sausage or snake, smooth and soft Soft blobs with clearcut edges (passed easily) Fluffy pieces, a mushy stool Type 7 Watery, no solid pieces ENTIRELY LIQUID Reproduced by kind permission of Dr K. W. Heaton, Reader in Medicine at the University of Bristol March 2011 Page 21 of 31

22 Appendix 3 Patient Information Leaflet: A simple guide to C.Difficile This guide explains what C.Difficile is, how it developed and ways in which it can cause infection. What is C.Difficile? C.Difficile is an abbreviation of Clostridium Difficile and it is the major cause of antibioticassociated diarrhoea and colitis, an infection of the intestines. It is part of the Clostridium family of bacteria, which also includes the bacteria that cause tetanus, botulism, and gas gangrene. It is an anaerobic bacterium (i.e. it does not grow in the presence of oxygen) and produces spores that can survive for a long time in the environment. It most commonly affects elderly patients with other underlying diseases. C.Difficile background and a short history Although C. Difficile was first described in the 1930s, it was not identified until the late 1970s as the cause of diarrhoea and colitis following antibiotic therapy. Even once this was recognised, laboratory diagnosis was difficult and the number of cases was not monitored. Lab tests have identified over 100 different types of C.Difficile. One of these, type 027, is of particular concern because it causes a greater proportion of severe disease and appears to have a higher mortality. It also seems to be very capable of spreading between patients. Type 027 was found to be the main cause of infection in the outbreaks of C.Difficile at Stoke Mandeville Hospital and elsewhere that have been investigated since Since January 2004, C.Difficile has been part of the mandatory surveillance programme for healthcare associated infections. What does C.Difficile cause in patients? C Difficile can cause diarrhoea, ranging from a mild disturbance to a very severe illness with ulceration and bleeding from the colon (colitis) and, at worst, perforation of the intestine leading to peritonitis. It can be fatal. Most of those affected are elderly patients with serious underlying illnesses. Most infections occur in hospitals (including community hospitals), nursing homes etc, but it can also occur in primary care settings. How do patients become infected? C.Difficile bacteria can be found living in the large intestine of a small proportion (less than 5%) of the healthy adult population. It is also common in the intestine of babies and infants. It is normally kept in check by the good bacterial population of the intestine. But when these good bacteria have been killed off by antibiotics, C.Difficile is able to multiply in the intestine and produces two toxins that damage the cells lining the intestine. The result is diarrhoea. March 2011 Page 22 of 31

23 Because it develops in this way, the patients who are most at risk of infection with C.Difficile are those who have been treated with broad spectrum antibiotics (those that affect a wide range of bacteria, including intestinal bacteria). Although some people can be healthy carriers of C.Difficile, in most cases the disease develops after cross-infection from another patient, either through direct patient to patient contact, via healthcare staff, or via a contaminated environment. A patient who has C.Difficile diarrhoea excretes large numbers of the spores in their liquid faeces. These can contaminate the general environment around the patient s bed (including surfaces, keypads, and equipment), the toilet areas, sluices, commodes, bedpan washers, etc. They can survive for a long time and be a source of hand-to-mouth infection for others. If these others have also been given antibiotics, they are at risk of C. Difficile disease. What can we do to prevent infection? 1. Always wash your hands after you have had any physical contact with a patient. Do not rely solely on alcohol gel as this does not kill C.Difficile spores. 2. To keep cases of C.Difficile down, healthcare workers should look to avoid prescribing broad spectrum antibiotics, as far as possible, so that patients natural protection is not weakened 3. If you suspect infection, there is a simple diagnostic test that can be done on a sample of diarrhoeal faeces to see if C. Difficile toxins are present. It gives a result within a few hours. In outbreaks, or for surveillance of the different strains circulating in the population, C. Difficile can be cultured from faeces and the isolates sent to the Anaerobe Reference Laboratory (National Public Health Service, Wales; Microbiology, Cardiff) or HPA Regional Laboratories for typing and testing for susceptibility to antibiotics. 4. Infected patients should be isolated and healthcare workers dealing with them should wear gloves and aprons, especially when dealing with bedpans, etc 5. Environments should be kept clean at all times. Where there are cases of C. Difficile infection, a disinfectant containing chlorine or other sporicidal agent should be used to reduce environmental contamination with the spores. March 2011 Page 23 of 31

24 Appendix 4 SCREENING TOOL. To be completed immediately for a patient suspected or discovered to have CDAD. Responsible person who ensures this form is completed: Nurse in Charge ACTIONS Escalate to contacted cleaners Patient isolated within 4 hrs of suspected CDT associated diarrhoea. Patient must be isolated on ward if the patient is not a suitable candidate for transfer or if no beds available. Documented time of isolation Place contact precautions signage outside door. Ensure gloves and aprons available outside room. Ensure a Hand wash reminder inside room. NB Remove alcohol gel from single room and bedside locker. Patient has own toilet or commode. Complete and record in the notes: 1. Bristol stool chart (each shift) If bowels not open record end of shift as BNO). 2. Fluid balance chart 3. Mews score 4 Daily Weight 5. Severity grading. Pharmacy review of antibiotics weekly. Consultant review Environmental cleaning review confirmation patient has information leaflets High Impact Intervention number 7 completed (7 observations to be done weekly Person responsible Nurse in charge Nurse in charge Nurse in charge Nurse in charge Nurse in charge Nurse in charge Nurse in charge Nurse in charge Nurse in charge Nurse in charge Nurse in charge Nurse in charge Matron Signature March 2011 Page 24 of 31

25 Appendix 5 Clostridium Difficile Care plan. Surname: Forename: Patient ID Number Actual / Potential Problem (delete as appropriate) Patient suffering from suspected Clostridium Difficile Associated diarrhoea Expected Result agreed by Nurse and Patient Patients will be afforded comfort, privacy and dignity throughout their illness. The patient will be kept fully informed as to the causes, and management and implications of their diarrhoea. Patients will be receive timely and appropriate nursing care to alleviate symptoms and prevent complications related to fluid/electrolyte loss, comprised skin integrity and nutritional issues. 1.Commence on a stool chart to monitor frequency, type and amount 2. Assess whether the patient has been on antibiotics, is constipated or received laxatives or enemas or recently under gone a surgical procedure or nutritional supplements If the patient has been prescribed any of the above inform staff and take appropriate action 3.Obtain a faeces specimen for CDT Date specimen sent to Bacteriology Signature of Registered Nurse 4. Commence. on a strict fluid balance chart (if appropriate). If oral fluids poorly taken, inform medical staff, consider prescribing intravenous therapy 5. Ensure that blood samples for U&Es are taken as indicated. 6. Ensure that a food and drink record chart is completed if dietary intake poor or requires monitoring. March 2011 Page 25 of 31

26 7. If diarrhoea persists, refer to dietician Date referred to dietician 8. Review patients pressure areas, taking appropriate action ensure that the patient is commenced on a Pressure Area Care care plan. 9. Medical staff must review all the patient s current prescribed antibiotics to ensure that they are necessary and appropriate. 10. The patient must be isolated (refer to Trust Policy for infection control precautions)/ in an appropriate single room with a toilet /commode for own use/ 12. Ensure the patient and relatives are given copies of a Patient Information Leaflet Clostridium Difficile Associated Diarrhoea. 13. Provide hand washing facilities for the patient. Explain to the patient the need for thorough hand washing after toilet/commode use and before eating. Supply soap and water wipes to patients with reduced mobility. 14. Infection control link nurse / team to offer support as required to patient, relatives and carers. 15. All staff must ensure that the policy for Clostridium Difficile Toxin and the High Impact Intervention Number 7 care bundle is fully adhered to. 16. A definitive diagnosis of CDT must be reported via the paper IR1 form or electronic incident reporting by a Registered Nurse the day of the diagnosis Date reported. Signature of Registered Nurse 18. If.. has not experienced any diarrhoea for 48 hrs isolation precautions can be stopped. 19. If the patient is transferred or discharged to nursing/residential home or hospital ward nursing staff must inform receiving staff of patient s CDT status. Registered Nurse signature March 2011 Page 26 of 31

27 Date care plan commenced Care Planned by (name and signature) Date and time: Designation: March 2011 Page 27 of 31

28 Appendix 6 HIGH IMPACT INTERVENTION NO 7 AIM: REDUCE THE RISK OF INFECTION FROM AND THE PRESENCE OF CLOSTRIDIUM DIFFICILE. Elements of the clinical process The elements of the care listed below are based on the EPIC guidelines and form the basis of reducing the risk of bacterial contamination. icyandguidance/dh_ Prudent antibiotic prescribing Prescribe antibiotics according to national guidance and local policy; minimise use of broad spectrum antimicrobials Review antimicrobial medication daily Include stop dates in antimicrobial prescriptions Hand Hygiene Wash hands with soap and water before and after each contact with symptomatic patients with Clostridium Difficile associated diarrhoea. (CDAD) Implement clean your hands campaign trust wide and ensure staff wash hands following direct patient care as above. Environmental Decontamination Implement enhanced cleaning in areas with CDAD patients Use chlorine based disinfectant or other sporicidal products to reduce environmental contamination with Clostridium Difficile spores as per local policy. Actichlor Plus solution or Neutral detergent and water followed by Haztab solution Ensure thorough cleaning and disinfection of environment and equipment in rooms following discharge of CDAD patients. Personal protective equipment Wear disposable plastic apron and gloves when handling body fluids and caring for symptomatic CDAD patients. Isolation Always use a single room if available Cohort patient care for CDAD patients should be applied if single rooms are not available. March 2011 Page 28 of 31

29 High Impact Intervention No 7 Audit Form 5 elements of high impact intervention are observed 7 times, each week for each patient associated with CDI. WARD/AREA MONTH AUDITOR Elemen ts Observ ation Prudent Antibiotic prescribing Hand washing before and after patient contact + correct cleansing agent and technique used Environmental and equipment decontamination Actichlor Plus solution or Neutral detergent and water followed by Haztab solution Personal Protective equipment Single room cohort used All elements performed Yes No Yes No Yes No Yes No Yes No Yes No Total % Complia nce March 2011 Page 29 of 31

30 Appendix 7 Taken from current health care policy; DH (2009) Clostridium Difficile: How to deal with the problem. CLINICAL GUIDANCE Severity Treatment Modality Setting Mild CDI is typically associated with <3 stools of types 5 7 on the Bristol Stool Chart per day. B Moderate CDI is associated with a raised WCC that is <15 x 10 9 /L; is typically associated with 3 5 stools per day. C Severe CDI is associated with a WCC >15 x 10 9/L, or an acute rising serum creatinine (i.e. >50% increase above baseline), or A temperature of >38.5 C, or evidence of severe colitis (abdominal or radiological signs). The number of stools may be a less reliable indicator of severity. C P Persistent diarrhoea The severity of a patient s symptoms and therefore illness must be assessed for all cases to ensure that the appropriate medication is prescribed. If diarrhoea persists despite 20 days treatment but the patient is stable and the daily number of type 5 7 motions has decreased, the WCC is normal, and there is no abdominal pain or distension, the persistent diarrhoea may be due to post-infective irritable bowel syndrome Recurrent diarrhoea 1. First recurrence: The severity of a patient s symptoms and therefore illness must be assessed for all cases to ensure that the appropriate medication is prescribed. 2. Subsequent recurrences: The severity of a patient s symptoms and therefore illness must be assessed for all cases to ensure that the appropriate medication is prescribed. Mild CDI Oral metronidazole for days mg tds. Diarrhoea should resolve within 1-2 weeks Moderate CDI Oral metronidazole for days mg tds Severe CDI Initially oral vancomycin 125mg qds for days In severe CDI cases not responding to oral doses +/- intravenous metronidazole is recommended. The addition of oral rifampicin or intravenous immunoglobulin may also be considered TRANSFER PATIENT TO ACUTE HOSPITAL Persistent diarrhoea The patient may be treated with an antimotility agent such as loperamide (instead of metronidazole or vancomycin). The patient should be closely observed for evidence of a therapeutic response and to ensure there is no evidence of colonic dilatation. REFER TO GP OR MEDICAL MICROBIOLOGY Recurrent Diarrhoea 1.Repeat the same antibiotic used to treat the initial episode(unless the first episode was treated with metronidazole and the recurrence is severe CDI in which case vancomycin should be used) 2. Oral doses. Refer to guidelines, as above. Consider alternatives (Halsey J 2008) DISCUSS WITH MEDICAL MICROBIOLOGIST OR GP. Community: Home or In-patient unit Community: Home or In-patient unit Emergency/ Acute unit Community: Home or In-patient unit Community: Home or In-patient unit March 2011 Page 30 of 31

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