C SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY: BOARD OF DIRECTORS 21 MARCH 2012 Subject: C.difficile Action Plan 2012/2013 Supporting Director: Professor Hilary Chapman, Chief Nurse/Chief Operating Officer Author: Mr Chris Morley, Deputy Chief Nurse Status (see N footnote): PURPOSE OF THE REPORT: This paper describes the actions that are being proposed to ensure the Trust achieves the C.difficile target for 2012/2013. KEY POINTS: The Trust did not achieve the C.difficile target for 2011/2012 of 134 The failure to achieve this target has been notified to Monitor The attached action plan builds on the successful implementation of the 2011/2012 recovery action plan which has seen a reduction of C.difficile cases to less than 10 a month for 5 consecutive months The cost of implementing this plan is approximately 1 million IMPLICATIONS: Achieve Clinical Excellence Be Patient Focused Engaged Staff Need to maintain the Trust s reputation for high standards on infection control Important element of patient safety Need to ensure that staff are aware of the importance of meeting the C.difficile target in 2012/2013 RECOMMENDATION(S): It is recommended that TEG approve the action plan to reduce C.difficile in 2012/2013. APPROVAL PROCESS: Meeting Date Approved TEG 29 February 2012 Board of Directors 21 March 2012 Status: A = Approval A* = Approval & Requiring Board Approval D = Debate N = Note Clostridium difficile Action Plan (2012/2013 version 4) 1
CLOSTRIDIUM DIFFICILE ACTION PLAN 2012/2013 Action plan to reduce the number of cases of Clostridium difficile (C.diff) at Sheffield Teaching Hospitals NHS Foundation Trust ACTION KEY MILESTONES PERSON RESPONSIBLE COMMENTS 1 Reducing Contamination on High Risk Wards 1.1 Maintain a deep clean programme that ensures at least 6 wards per month are deep cleaned at the Northern General Hospital and 2 wards per month on the Central Campus. This will be monitored by the C.difficile Executive Group. 1.2 Retain a deep clean team to work flexibly across both the Royal Hallamshire Hospital and the Northern General Hospital sites, enabling deep cleaning including the use of Hydrogen Peroxide Vapour as part of a deep clean programme. Start Start 1 April 2012 Hotel Services Director 1.3 Ensure that there is available capacity on both hospital campuses to allow the deep clean programme to be delivered using a combination of bay by bay cleaning and decant cleaning. 1.4 Produce and disseminate a guide for wards on what audits and actions should be taken to minimise the incidents of C.difficile covering normal working, high incidence wards and cluster wards. 1.5 Remove all radiator covers on inpatient wards and clean the radiator and cover prior to the heating being turned on for winter. Start date 1 July 2012 Start 1 April 2012 Document disseminated by 1 April 2012 Start date 1 July 2012 Deputy Chief Operating Officer Deputy Chief Nurse Hotel Services Director 1.6 DIFFICIL-S will be used as standard on medical assessment units, surgical assessment centre, Haematology Unit, Weston Park Hospital. It will also be used following any individual cases of C.difficile and in any areas identified as being of concern. Clostridium difficile Action Plan (2012/2013 version 4) 2
2 Optimising Infection Practice 2.1 All inpatient areas to gain or maintain Infection Control Accreditation. This requires compliance with both the commode and C.difficile care bundle audits. This will be monitored via the Infection Control Committee. 2.2 The Infection Team will ensure that there is an assurance process in relation to the commode audits undertaken on each inpatient ward. 2.3 Every ward area (excluding those using DIFFICIL-S ) to be cleaned in all areas using Chlorclean during the first week of each month. 2.4 For high incidence wards not identified to use DIFFICIL-S, Chlorclean to be used as standard for cleaning. 2.5 If national recommendations become available on the laboratory testing and diagnosis of C.difficile, these will be reviewed and a gap analysis prepared against the recommendations within 1 month of their publication. Determined by the publication of any national recommendation on C.difficile testing Director of Infection 2.6 The revised criteria implemented on the information required on sending a stool sample is to be continued. Compliance with this requirement will be monitored and published weekly and reviewed by the C.difficile Executive Group. 2.7 Agree a Trust-wide plan for disposal of used water to reduce the likelihood of contamination of hand-wash sinks with C.difficile and pseudomonas spp. Awaiting Department of Health guidance Deputy Chief Nurse Clostridium difficile Action Plan (2012/2013 version 4) 3
3 Evidence Based Prescribing 3.1 Ciprofloxacin to remain restricted to those inpatient areas agreed in 2011. 3.2 Antibiotic prescribing will continue to be audited quarterly as part of the Infection Control Accreditation. 3.3 An audit of the Chest Infection Guideline / Bundle will take place to check compliance. 3.4 Update the Proton Pump Inhibitors (PPI) guidelines to clarify when it is appropriate to stop PPIs. 1 April 2012 Medical Director Achieved 30 September 2012 Director of Infection 30 September 2012 Medical Director 4 C.diff Case Follow Through and Actions 4.1 Cases of C.difficile will remain subject to a department based root cause analysis to be returned centrally. 5 Further Raising the Profile of Infection 5.1 An internal communications strategy will continue to be implemented to highlight the importance of infection prevention and control. 1 April 2012 Communications Director 5.2 The C.diff operational group comprising Deputy Chief Nurse, Director of Infection Prevention and Control, Lead Infection Control Nurse, Infection Control Doctor, Hotel Services Director and Antibiotic Pharmacists, will continue to be held throughout the year. The frequency will be determined by performance against expected trajectory on C.difficile. 5.3 A campaign on infection prevention and control for 1 April 2012 Communications Director the public will continue to be implemented throughout 2012. Clostridium difficile Action Plan (2012/2013 version 4) 4
6 Monitoring 6.1 A weekly email will be sent to Clinical Directors, Medical Infection leads, Nurse Directors, Matrons and Lead Nurses from the Director of Infection regarding the number of C.difficile cases recorded each week. Clostridium difficile Action Plan (2012/2013 version 4) 5