Report to: Trust Board Agenda item: 8C Date of Meeting: 29 January 2014 Title of Report: Report on RUH C diff Cases April December 2013 Status: For Approval Board Sponsor: Helen Blanchard, Director of Nursing/DIPC Author: Yvonne Pritchard, Senior Infection Prevention and Control Nurse Appendices Appendix 1: HCAI Recovery Plan 1. Purpose of Report (Including link to objectives) The Trust is set an annual trajectory for Clostridium difficile reduction; the target for 2013-14 is no more than 29 cases. The Department of Health defines that a C difficile infection case is trust acquired when a positive stool sample is taken three or more days after admission. All confirmed cases of infection are reported through the Public Health England HCAI Data Capture Tool; by the end of December the Trust had reported 28 cases with a further three months remaining before the end of the financial year. This report provides an overview of the cases of C difficile that have been recorded as Trust acquired. 2. Summary of Key Issues for Discussion The report highlights the work that is being done to reduce the incidence of Clostridium difficile infection. This work forms part of the HCAI recovery plan. The six key areas for C difficile infection reduction are: 1. Appropriate stool sampling 2. Prompt isolation of patients with diarrhoea promptly 3. Consistent communication between wards 4. Cleaning of the environment and equipment 5. Antibiotic stewardship 6. Compliance with hand hygiene standards The majority of patients affected had at least two risk factors that would have predisposed them to C difficile infection with antibiotics featuring in all but two of the cases. Antibiotic stewardship is one of the biggest challenges that is currently being addressed and the antimicrobial pharmacist and microbiologists are working together to improve compliance with prescribing guidelines across the Trust. The Commissioners have met with the Infection Prevention and Control Team to review a number of the C difficile cases and have agreed that at least 5 cases will not be counted against the trajectory. A further case is also under review and if this is agreed the number of cases counted will be 22. Version: 1 Agenda Item: 8C Page 1 of 11
3. Recommendations (Note, Approve, Discuss etc) To update and inform the Board of the number of C difficile cases year to date and actions being taken to prevent further incidences. 4. Care Quality Commission Outcomes (which apply) Outcome 8: Cleanliness and Infection Control 5. Legal / Regulatory Implications (NHSLA / Value for Money Conclusion etc) Care Quality Commission Registration 2013/14. 6. NHS Constitution 3a. Patients and Public Quality of care and environment 7. Risk (Threats or opportunities link to risk on register etc) 1. Failure to achieve annual target may affect Foundation Trust application. 2. Trust Risk Register entries: 188 Hygiene Code Compliance, 180 Lack of Isolation Facilities. 8. Resources Implications (Financial / staffing) There could be financial penalties if C difficile target is not met. 9. Equality and Diversity No issues identified. 10. Communication Actions required as part of the HCAI recovery plan will be discussed at the Infection Prevention and Control Committee and disseminated through the divisions. 11. References to previous reports Report on RUH C diff cases April September 2013. 12. Freedom of Information Public Agenda Item: 8C Page 2 of 11
Report on Trust Attributable Clostridium difficile cases at the Royal United Hospital Bath NHS Trust from 1 April to 31 December 2013 1.0 Background information The mandatory surveillance of patients over the age of two with Clostridium difficile infection commenced nationally in April 2007. All toxin positive cases are reported via the web-based Healthcare Associated Infections Data Capture Tool which is supported by Public Health England. Significant year on year reductions in C difficile infections have been recorded in the years since surveillance began and the associated trajectories have also decreased annually. There is a gap in the data available for 2007 however the graph below shows cases from April 2008 onwards. Fig. 1 Monthly and cumulative Clostridium difficile trajectory April 2008 December 2013 From April 2012 the trajectories were reduced further and achievement of the targets has become more challenging due to the low number of cases that are accepted. In October 2012 testing for C difficile infection changed to meet the Department of Health standard of having two tests to detect the presence of the organism and identify whether toxins were produced. Since the new testing regime was introduced Agenda Item: 8C Page 3 of 11
there has been a rise in the number of toxin positive cases however there is no identifiable reason for this to have occurred. Fig. 2 Clostridium difficile infections April 2012 December 2013 In December 2012 a teleconference was held between Trust representatives including the CEO, Medical Director and DIPC and representatives from Department of Health, NHS England and commissioners. All cases of C difficile infection for the year were discussed and it was agreed that the commissioners would meet with the Trust Infection Prevention and Control Team (IPCT) to undertake a further strategic review of each individual case. This meeting took place in January 2013 where agreement was made that some reported cases would not be counted by the commissioners against the RUH trajectory. The non-counted cases included patients who had been admitted with the infection however stool samples were not obtained within the first three days of admission and some patients with recurring infections which were agreed as not attributable to the Trust. This agreement has continued in 2013-14 and year to date there have been 6 cases referred to the Commissioners. There has been agreement that 5 of these cases will not be counted against the trajectory whilst a decision is awaited on the sixth case. All cases however have been reported to Public Health England via the HCAI Data Capture System. Of the cases that have not been counted 1 patient had continuing infection that was acquired previously, 3 patients who had no clinical signs of infection and were not treated for C difficile, and 1 patient who was admitted with symptoms however the sample taken on admission was mislaid between leaving the ward and arriving in the laboratory. It was 3 days before this was identified and a second sample was taken however by the time it was received the case was classed as Trust acquired. The Agenda Item: 8C Page 4 of 11
sixth case that is currently being considered was another patient with continuing infection who had continued to have symptoms despite treatment with the appropriate antibiotics. Fig. 3 Clostridium difficile cases 2013-14 (recorded) Fig. 4 Clostridium difficile cases 2013-14 (counted, with 6 cases removed) Agenda Item: 8C Page 5 of 11
2.0 Clostridium difficile recovery plan A C difficile recovery plan was commenced in January 2013 and this was presented to the Management Board for approval. In December 2013 the C difficile recovery plan was merged into the HCAI recovery plan which also covers MRSA reduction. There are six key areas that are the focus for C difficile reduction in the action plan: 1. Appropriate stool sampling 2. Prompt isolation of patients with diarrhoea 3. Consistent communication between wards 4. Cleaning of the environment and equipment needs to be improved 5. Antibiotic stewardship 6. Compliance with hand hygiene standards needs to be maintained in all clinical areas. Progress is monitored through the Infection Prevention and Control Committee and a weekly compliance report is sent out to matrons and other key personnel. 2.1 Appropriate stool sampling During 2012-13 there were a number of cases where patients who were asymptomatic were found to have Clostridium difficile infection. These patients did not have diarrhoea and had no signs of infection however stool samples were taken by staff which were tested as C difficile toxin positive. In order to address this, the IPCT carried out focused teaching sessions on wards and stool sampling guidance was included in mandatory training. A stool testing algorithm was rolled out and this was also adapted on the ICE pathology system so that all staff ordering C difficile tests would check the algorithm first. Systems were also introduced temporarily to have sign off of samples by senior nursing staff and sample pots obtained from the IPCT. These processes were reviewed after approximately six weeks and only a small drop in the number of samples taken was evident. All cases of C difficile infection are investigated by root cause analysis and are reviewed at a multidisciplinary meeting. Learning from these investigations is disseminated through the Infection Prevention and Control Taskforce. A Trust wide campaign has been launched to focus on leadership and education relating to the reduction of health care associated infections. The Infection Matters campaign includes hand hygiene, antibiotic stewardship and the taking of appropriate samples. This was launched at an Open Staff Meeting and posters will be installed across the site reminding staff of their role in reducing infections. Agenda Item: 8C Page 6 of 11
2.2 Prompt isolatation of patients with diarrhoea Lack of adequate isolation facilities remains a high risk and this is recorded on the Trust risk register. Focus within the recovery plan is on optimal use of side rooms. The daily ward visits by the IPCT have helped to enforce the requirement for patients to be isolated promptly. A two hour standard has been introduced for isolation from the time that a side room is requested to when the patient is transferred to the room. All exceptions to this rule must be reported to the Site Team and further delays documented on DATIX. Isolation room use has also been included in ward safety briefings. A new SBAR transfer checklist was introduced in early 2013 so that communication between transfer and receiving wards is improved and its use will be audited. 2.3 Consistent communication between wards When patients with infections are transferred from one ward to another there must be good lines of communication between both areas. There is an internal transfer form which is based on SBAR principles and it should be used to document a patient s infection risks along with several other key pieces of information relating to patient safety. The form is used by MAU for all patient transfers however it is seldom used by other ward staff. Use of the form needs to roll out across the Trust so that information given on all internal patient transfers is documented in the same way. 2.4 Environmental cleaning and decontamination of equipment A deep clean programme was commenced during June and July 2013 and wards where there was a considerable risk of contamination from C difficile spores were targeted. These included areas where there had been confirmed cases and also admission areas. All of the high risk areas were completed therefore the programme rolled out to include other wards. A trial of twice daily thorough cleaning of side rooms was introduced however this was challenging to complete due to staffing levels within the Cleaning Department. Following a review it was decided that all side rooms where patients with C difficile are nursed would have a thorough clean once a day. Recruitment to vacant posts in Cleaning has continued during 2013 and a number of new starters have joined the Trust during the year. A rolling recruitment programme will continue so that posts remain filled. Ward staff were also reminded that decontamination of equipment is vital in order to reduce C difficile spore contamination. Cleaning advice has been included in mandatory training programmes and regular audits of equipment decontamination undertaken, e.g. commodes. Agenda Item: 8C Page 7 of 11
In support of these initiatives the IPCT commenced daily visits to all inpatient ward areas to monitor both environmental and equipment cleanliness as well as keeping a focus on patients with known or suspected infections. 2.5 Breaches in antimicrobial stewardship The antimicrobial pharmacist has introduced more antibiotic ward rounds with the microbiologists and ward pharmacists where possible. This has helped to increase the microbiologist s visibility and made their expertise more accessible to junior medical staff. The team also see all patients with C difficile infection or colonisation and advise on treatment. The antibiotic prescribing policy, empirical treatment guidelines and C difficile treatment guidelines have been revised. The C difficile treatment guidelines have also been published and all of the documents are now available on the intranet. The Trust drug prescription chart has been revised and a new dedicated antibiotic section added. The aim of this is to keep all anti-infective medications in one place so that medical and nursing staff can easily identify the number of courses prescribed and also to encourage early review of antibiotics and documentation of stop dates. Monthly antibiotic prescribing audits are carried out on each ward area and the results are shared with the clinical leads. The audits are broken down by clinician so that they can monitor performance and identify whether guidelines have been adhered to. Antibiotic prescribing training was included in the induction programme for all new F1 and F2 doctors in August 2013. This has been set up to run at future medical induction sessions so that new staff are familiarised with the Trust guidelines and policy. The antimicrobial pharmacist developed the ASPIRE campaign to highlight good prescribing practice during 2013. This is part of Infection Matters and the guidance can be used by prescribers and dispensers to improve compliance with the Trust policy. Following on from this successful campaign a new programme called RID has been introduced to provide and easy to remember message around antibiotic prescribing: Review all antibiotics daily Indication why have they been prescribed? Document plan in the patient s medical record and on the prescription chart. To further improve compliance with Trust policy the antimicrobial pharmacist is also looking into the possibility of using the Microguide app which can be accessed by staff using smart phones. There is a financial cost associated with developing the app however this may be out-weighed by the use it would have, particularly by junior doctors who may need to access prescribing guidelines at any time during the day or night. Agenda Item: 8C Page 8 of 11
2.6 Maintain compliance with hand hygiene standards Hand hygiene posters have been placed around the Trust as part of the Infection Matters campaign in order to remind staff that hand hygiene remains a strong focus for preventing infections. The matrons have been tasked with continuing to promote hand hygiene practice by use of the Glo boxes as teaching aids. The Infection Prevention and Control Team have also delivered local training in hand hygiene in areas where there has been a high prevalence of C difficile infection and colonisation. Monthly hand hygiene audits are continuing in all clinical areas and results are reviewed at the Infection Prevention and Control Committee meeting. 3.0 Assessment of C difficile cases from 1 April 2013 From 1 April 2013 all cases of C difficile have been reviewed by the microbiologists and case note reviews of all Trust attributed cases have also been undertaken by the Infection Control Doctor and the Senior Infection Prevention and Control Nurse. From the case note reviews it has been possible to identify risk factors and some common themes, see Fig. 5. The age of the affected patients and administration of antibiotics were the highest risk factors for these patients.26/28 (93%) patients had two or more risk factors associated with the acquisition of C difficile infection. All of the patients were aged 65 years and over; the elderly are the most at risk from C difficile and nationally this age group accounts for more than 80% of all cases reported. The average length of stay for the affected patients was 37.1 days; the shortest length of stay at the time of diagnosis of C difficile infection was 5 days with the longest being 168 days. Prolonged length of stay and recent admission to hospital are known to increase the risk of patients acquiring the infection as the likelihood that antibiotics will be or have been prescribed increases and they may be contact with other patients with the infection. 26/28 (93%) of affected patients had received antibiotics in the preceding 3 months; in the majority of cases these were found to be prescribed correctly and were given appropriately. There were two cases where prescribing was not in line with Trust policy and in both cases the relevant clinicians were contacted to address these issues. The antimicrobial pharmacist and microbiologists also identified a small number of cases where the course length could have been shortened slightly and the switch from intravenous to oral therapy made earlier. These factors have been included in the revised antibiotic prescribing policy and will form part of future teaching sessions with medical staff. Agenda Item: 8C Page 9 of 11
7/28 (25%) patients had history of previous infection or colonisation which exposed them to the risk of developing further infection with the organism. It is reported by Public Health England that 20% of cases will relapse and become re-infected. Other risk factors highlighted from the case note reviews were use of proton pump inhibitors (PPIs), enteral feeding and gastrointestinal tract surgery or endoscopic procedures in the last 3 months. Fig. 5 C difficile case risk factors April December 2013 4.0 Other factors 4.1 Community acquired cases Between April and December 2013 there were 22 pre-72 hour (non-trust attributable) C difficile cases recorded. All of these patients had symptoms on admission to the Trust and were admitted for treatment. There were also 63 GP and community hospital cases reported during this period. Of these cases 16 were admitted to RUH for treatment. The presence of these patients on wards would have increased the environmental contamination levels and other patients could have been exposed to infection. 4.2 Limited number of isolation facilities Patients with diarrhoea must be transferred to side rooms however due to the limited number of rooms available it may not always be possible to keep them within their specialty. Ideally patients should stay in isolation until their treatment has been completed and they no longer have symptoms. Unfortunately there are times when Agenda Item: 8C Page 10 of 11
patients are brought out of their side rooms before treatment has been completed in order to accommodate other patients with infections. Symptoms may restart once treatment is complete and this will expose other patients to the risk of infection. 4.3 Infection risk alerts All patients with C difficile infection or colonisation will have infection risk alerts placed on Millennium by the IPCT. These alerts should be left on the system as this helps to identify those patients who are readmitted and assists with the early identification of potential infection risks. Any member of staff with a clinical level of access to the patient s record can add or remove these alerts. On a number of occasions alerts have been removed by staff who do not work in the IPCT as they have thought that there is no longer a risk. As a result this we cannot identify previously infected or colonised patients when they are admitted. 5.0 Conclusion From April to December 2013 28 patients have acquired C difficile infection whilst admitted to Royal United Hospital Bath NHS Trust. 5 cases have not been counted by the commissioners with a sixth cases awaiting review, see page 2 of report. There are a number of factors that have led to the patients developing the infection and many of these patients have very complex medical histories. The biggest risk factor is the use of antibiotics; the prescribing policy and guidelines have been revised to improve antibiotic selection and stewardship and compliance will be monitored through regular audits. Actions to further reduce the occurrence of infection have been included in the HCAI recovery plan (Appendix 1). Agenda Item: 8C Page 11 of 11