Appendix 1: C.diff elements with the Trust s HCAI recovery Plan and Risk to Delivery Issue Action Risk to Year-end trajectory for C difficile infections is 29 cases. Week commencing 09.12.13 - Performance year to date is 22 (counted) cases. There must be no more than 2 cases per month until 31.03.13. Key factors to be addressed: 1. Inappropriate stool sampling 2. Failure to isolate patients with diarrhoea promptly. 3. Communication between wards is not consistent. 4. Cleaning of the environment and equipment needs to be improved. 5. Breaches in antibiotic stewardship. 6. Maintain Stool samples must be authorised by the nurse in charge/shift coordinator before they are sent to the laboratory. All patients with suspected potentially infectious diarrhoea must be isolated within 2 hours. Daily stool sampling records collected by. Monitor and report compliance with stool sampling documentation on weekly C diff performance report. 1. Patients with diarrhoea must be isolated in a single side room with a self-contained toilet or commode. This is included in mandatory and induction training. A-Z isolation priorities to be sent to all wards. 2. The patient must remain isolated until there have been no symptoms for a least 48 hours and a formed stool has been passed. 3. All delays in isolation to 31.12.13 31.12.13 and action on-going with ongoing actions On-going Ward sisters/matrons/ Stool sampling authorisation records. Records collected daily from wards and crossreferenced with laboratory records. Senior IPCN Weekly reports Weekly report sheet sent out to senior nurses. Non-compliance must be followed up by matrons Ward sisters/matrons Ward sisters/matrons All staff records records Datix reports A-Z isolation priorities sent to ward sisters and matrons. will monitor patients who are isolated during the daily ward visits. Incidents are Agenda Item: 8C Page 1 of 10
compliance with hand hygiene in all clinical areas. be logged as patient safety risks daily in the site office and reported on DATIX if not achieved in 2 hours. action IPCC minutes monitored through the IPCC Monitor usage of side rooms daily. Improve the quality of infection risk information during patient transfer between wards by using the SBAR form. Red 1. Daily ward IPCN visits to identify patients requiring isolation. 2. Patient safety briefings to cover isolation room use. to attend safety briefings ad hoc to ensure that infection risks are covered. 3. Document daily side room usage of spread sheet managed by Site Team. 1. SBAR form to be used for all patient transfers within the Trust. 2. Audit use of the form for communicating infection risks quarterly. On-going action 31.03.14 and ongoing Wards sisters/ Weekdays Weekends/BH Site Team Ward sisters Daily reports Side room tool on Admissions shared drive SBAR form in patient s record. Audit report SBAR form is only used by MAU currently and quality of information is variable. November 2013 audit results = 13% compliance. Discussion to be held at Senior Nurse meeting in February 2014 Agenda Item: 8C Page 2 of 10
All equipment used for patient care must be decontaminated appropriately between use. 1. All commodes must be cleaned between use, dated and labelled as clean. 2. If commodes are not used and are stored in a dirty utility room they must be cleaned at least once every 24 hours. 3. Commode cleanliness will be spot-checked daily and if they are found to be soiled this must be escalated via the appropriate route. 4. Commode cleanliness will also be checked weekly and reported to the. 5. All other patient equipment must be cleaned between patients, labelled and stored in a clean area when not in use. Monthly audits to be carried out using Saving Lives High Impact Intervention No 8 tool. 6. Trust wide audit of patient equipment cleanliness will be completed every six Ward sisters Ward sisters /Matrons Ward sisters Wards sisters Commode audit results Audit reports Audit report How to dismantle and clean a commode poster disseminated to all wards November 2013. November 2013 commode cleanliness audit achieved, 81%. This was an improvement on September s audit results of 68% Compliance will be monitored through IPCC July 2013 audit equipment 90% clean -22% labelled. Agenda Item: 8C Page 3 of 10
months. Re-audit commenced January 2014 Standards of environmental cleanliness must be improved so that all clinical areas meet agreed audit score levels. Very high risk areas = 98% High risk areas = 95% Significant risk areas = 85% 1. Deep clean within 4 hours to be introduced as a standard 2. C diff side rooms to be cleaned thoroughly with Actichlor Plus at least once a day. 3. Toilets to be cleaned three times a day 31.10.13 and ongoing 31.10.13 and ongoing 31.10.13 and ongoing Weekly C diff performance report Record sheets Weekly C diff performance report C diff side rooms cleaned daily including weekends 4. Revisit use of Hydrogen peroxide for cleaning of C diff side rooms 31.03.14 DIPC/Senior IPCN Use of Hydrogen peroxide has been explored previously however Estates expressed concerns regarding safety due to permeability of ceiling tiles. Agenda Item: 8C Page 4 of 10
1. Daily ward visits to include review of cleaning staff levels 2. Deep clean programme 2013 1. Recruit to vacant supervisors post so that there is appropriate supervision of cleaning staff across the Trust. and ongoing Daily records and weekly C diff performance report Cleaning establishment Plan for deep clean programme in 2014 is being prepared Cleaning action plan in place to support HCAI recovery plan 2. Completion of monthly audit programme to be 100% compliant. Training and Auditing Weekly report Progress reported to the Trust s IP&C Committee 3. Enhance cleaning hours from midnight to 6am through recruitment to posts covering these hours. 4. Provide an advice sheet for cleaners 5. Cleaning staff employed as damp dusters must be supervised by the designated cleaning supervisor., needs annual review manager Cleaning rotas Daily observation and testing of staff knowledge Agenda Item: 8C Page 5 of 10
Improve antibiotic stewardship and leadership C diff toxin positive and GDH positive patients to be reviewed by Microbiology team at time of positive sample and then weekly Introduce more antibiotic stewardship ward rounds, with ward s where possible. Target high risk elderly care and admission areas initially. Review medical microbiology input to clinical areas to support heightened clinical leadership visibility and support to medical staff. Microbiologists will continue to visit clinical areas daily as required. with ongoing action for MAU. Midford Pharmacist/ Microbiologists Pharmacist/ward s/ Microbiologists Pharmacist/ Microbiologists Documentation in medical notes of microbiology input on C diff positive patients. List of patients for review kept on Microbiology shared drive. Microbiology weekly/daily patient review list Weekly MAU ward rounds in place. Aiming to commence weekly ward round on Midford. Increase referrals for microbiologist review by implementation of IT based referral system. 31.03.14 Lian Herrin (IT) and Pharmacist IT system functional but referral process to be refined. Agenda Item: 8C Page 6 of 10
Review the use of Empirical Treatment of Infections Guidelines Antibiotic Prescribing Policy to be re-written with an emphasis on start smart then focus when prescribing antibiotics Pharmacist/ Microbiologists Pharmacist/ Microbiologists New guidelines published. Policy on intranet Updated guidelines on intranet 07.01.14 Summary version distributed to wards and junior doctors. Project with IT for empirical guidelines to be available on intranet as a web based click through 31.03.14 Pharmacist and Louette Eagles (IT) Guidelines on intranet Awaiting IT to complete project. ASPIRE campaign to highlight good practice when prescribing antimicrobials Campaign materials on intranet Carry out Monthly Antibiotic Prescribing Indicators. Results reported by ward and for surgical wards, further broken down by consultant., on-going monthly feedback Reports Reports sent monthly to clinical leads Agenda Item: 8C Page 7 of 10
Share results of monthly Antibiotic Prescribing Indicators with clinical leads. Pharmacist/ Medical and Surgical division chairs Reports As above Display results of monthly Antibiotic Prescribing Indicators on individual wards. Review of Antibiotics received by all C diff positive patients. Were all antibiotics appropriate? Is co-amoxiclav a likely causative antibiotic? Share any lessons learnt. 28.02.14 / Ward sisters BIU input required. Results to be included in ward dashboards when available. Antibiotic specific section within Trust drug chart. More emphasis on review / stop dates. To reinstate antibiotic prescribing on F1/F2 training 28.02.14 / Microbiologists/ Senior IPCN Revised drug chart Drug chart designed. With printers 10.01.14. Update on antibiotic stewardship at F1 teaching 08.01.14. F2 teaching 23.01.14 MNPs 14.01.14 Agenda Item: 8C Page 8 of 10
Application for Fidaxomicin to be included in Formulary Formulary Update guidelines for treatment of C difficile Antibiotic review notices to go onto medicines charts to prompt reviews of antibiotics (used by s/nurses) Explore possibility of using Microguide app for antibiotic guidelines RID campaign piece for January @RUH to be written. /all s 31.04.14 Guideline published on intranet Distributed to s 08.01.14 Need to explore costs and resources for implementation Hand hygiene promotion to be enhanced so that materials are available in all public and clinical areas. Cost new materials to promote better hand hygiene Print new materials and display in a coordinated manner New Infection Matters campaign to be launched. The campaign will include hand hygiene, cleaning/de-cluttering, stool rules, ASPIRE antibiotic prescribing and overall C diff and MRSA reduction. IPC Nurse Communications Team Interim Head of Comms/DIPC/ Assistant DIPC/ Senior IPCN Communication materials Campaign materials Posters displayed throughout Agenda Item: 8C Page 9 of 10
Include bare below the elbows in hand hygiene campaign. Escalate to appropriate manager if staff are noncompliant following reminders. Matrons to continue local hand hygiene training with Glo boxes. /ADNs/ Matrons/Senior Sisters Included in Core Skills updates for medical staff. Glossary of Terms: IPC Infection Prevention and Control Infection Prevention and Control Team IPCN Infection Prevention and Control Nurse ICD Infection Control Doctor DIPC Director of Infection Prevention and Control MAU Medical Assessment Unit SAU Surgical Assessment Unit ANTT Aseptic Non Touch Technique IPCC Infection Prevention and Control Committee Agenda Item: 8C Page 10 of 10