Root Cause Analysis Investigation Report Clostridium Difficile Ian Monro Ward The Royal National Orthopaedic Hospital CONTENTS Incident description and consequences Pre-investigation risk assessment Background and context Terms of reference The investigation team Scope and level of investigation Investigation type, process and methods used Involvement and support of patient and relatives Involvement and support provided for staff involved Information and evidence gathered Chronology of events Detection of incident Notable practice Care and service delivery problems Contributory factors Root causes Lessons learned Recommendations Arrangements for shared learning Distribution list Appendices MAIN REPORT Incident description and consequences This 48yr old female was admitted into the Royal National Orthopaedic Hospital (RNOH) on the Private Patient Unit (PPU) on the 14 th March 2012 under the care of Mr Nejad for revision right total hip replacement. The patients past medical history is as follows: Bi lateral DDH Various osteotomy of right and left hip Removal of metalwork left hip 2011 Right uncemented total hip replacement 2000 Left hip arthrogram 2011 At RNOH the patient was sent to theatre on the 14 th March 2012. The patient was received back onto the ward at 18.30. The patient had no bowel movement on that day. The patient was given Prophylaxis antibiotics, three doses of iv cefuroxime 750mg as follows: 14/03/12 at 13.20 14/03/12 at 21.20 15/03/12 at 03.20
15/03/12 bowels opened, no concerns reported. 16/03/12 temperature raised to 38.5 C bowels opened large motion slightly soft stool. 17/03/12 had 3 x loose stool motion, sample sent to microbiology. The patient was already in a side room with single bathroom; barrier nursing and infection control precautions were initiated immediately. Diclofenac was omitted it was causing the patient stomach irritation and nausea. It is documented that the patient had one episode of loose offensive stool at 06.30. 18/03/12 Patient had 2 x loose stools, was seen by SHO at 15.30 and he confirmed that the stool sample had tested positive of Clostridium Difficile (CDI). Stool chart (based on the Bristol stool chart) was commenced and the patient was started on 500mg metronidazole three times a day as prescribed. The first dose was given at 16.00hrs. The Patient was then given advice on C.difficile by the medical team. Patient vomited after taking metronidazole anti emetics given before further doses with good effect. 19/03/12 actimel commenced at 08.00 as prescribed on dietician advice by the medical team. Patient continued to have Loose stools x 5. Repeat stool sample was sent and Metronidazole dose was changed to 400mg three times daily. 20/03/12 had 2 x small episodes of loose stools and vomited once. Seen by microbiologist and infection control for review and further information regarding the infection was given. 21/03/12 had 4 x episodes of loose stools, small amount and one episode of formed stool at 04.00. Seen by SHO who told patient she can go home on Thursday 22/03. No loose stools overnight into the 22/03. 22/03/12 Seen by Mr. Nejad who confirmed patient can go home. Advice given to patient on infection control procedures regarding C Diff, Infection control nurse was informed that the patient had requested a leaflet for information regarding C Diff. Patient sent home to continue with a ten day course of antibiotics and was discharged from ward. Incident date: 18 th March 2012 Incident type: Specialty: Patient confirmed with Clostridium difficile Infection (CDI) by stool sample results Private Patient Unit (Ian Munro ward) Effect on patient: Patient was lacking energy, felt nauseated and was upset with the whole situation. Severity level: severe Pre-investigation risk assessment A Potential Severity (1-5) B Likelihood of recurrence at that severity (1-5) C Risk Rating (C = A x B) 2 5 10 Background and context The investigation was undertaken using the Root Cause Analysis (RCA) toolkit. The toolkit provided a framework to ensure that relevant facts and information were collected. The purpose of the investigation is not to apportion blame but to be able to reflect on this case to establish if there was anything which the organisation could have done to prevent this case of C.difficile.
The investigation team Georgina Whorlow Staff Nurse PPU Michelle Bozier Ward sister PPU Zama Khumalo Infection Control Nurse Scope and level of investigation An investigation was undertaken by the investigators employed by the RNOH. This investigation and the results will be shared with the Infection Control Committee, Clinical Governance, the Clinical Risk Outcome Panel and the Clinical Quality Review Meeting held by Commissioners. Investigation type, process and methods used The investigation team met twice to review the medical nursing notes and to discuss the case. Involvement and support of patient and relatives The patient was seen by Dr Mack the microbiologist consultant from the Royal Free Hospital but was not involved in the process of this investigation. Involvement and support provided for staff involved The senior staff and the Infection Control Link will feed back the findings of the investigation of the RCA locally to all staff. Training issues identified will be addressed. Information and evidence gathered The patient s medical and nursing notes were used. Telephone calls to Microbiology department for more information. Chronology of events At RNOH the patient was sent to theatre on the 14 th March 2012. The patient was received back onto the ward at 18.30. The patient had no bowel movement on that day. The patient was given Prophylaxis antibiotics, three doses of iv cefuroxime 750mg as follows: 14/03/12 at 13.20 14/03/12 at 21.20 15/03/12 at 03.20 15/03/12 bowels opened, no concerns reported. 16/03/12 temperature raised to 38.5 C bowels opened large motion slightly soft stool. 17/03/12 had 3 x loose stool motion, sample sent to microbiology. The patient was already in a side room with single bathroom; barrier nursing and infection control precautions were initiated immediately. Diclofenac was omitted it was causing the patient stomach irritation and nausea. It is documented that the patient had one episode of loose offensive stool at 06.30. 18/03/12 Patient had 2 x loose stools, was seen by SHO at 15.30 and he confirmed that the stool sample had tested positive of Clostridium Difficile (CDI). Stool chart (based on the Bristol stool chart) was commenced and the patient was started on 500mg metronidazole three times a day as prescribed. The first dose was given at 16.00hrs. The Patient was then given advice on C.difficile by the medical team. Patient vomited after taking metronidazole anti emetics given before further doses with good effect. 19/03/12 actimel commenced at 08.00 as prescribed on dietician advice by the medical team. Patient continued to have loose stools x 5. Repeat stool sample was sent and Metronidazole dose was changed
to 400mg three times daily. 20/03/12 had 2 x small episodes of loose stools and vomited once. Seen by microbiologist and infection control for review and further information on regarding the infection was given. 21/03/12 had 4 x episodes of loose stools, small amount and one episode of formed stool at 04.00. Seen by SHO who told patient she can go home on Thursday 22/03. No loose stool s overnight into the 22/03. 22/03/12 Seen by Mr. Nejad who confirmed patient can go home. Advice given to patient on infection control procedures regarding C Diff, Infection control nurse was informed that the patient had request a leaflet for information regarding C Diff. Patient sent home to continue with a ten day course of antibiotics and was discharged from ward. Detection of incident: 18/03/12 at 15.30 SHO informed the ward and the patient of stool sample results. Notable practice 1. As soon as diarrhoea was evident a stool sample was sent and patient was barrier nursed. Patient was already in a single room with a single bathroom in it. 2. Infection control nurse was informed immediately. 3. A stool sample was collected and sent as soon as it was possible to do so. 4. Hand hygiene using soap and water was reinforced. 5. A nurse was designated to look after the patient to try and lesson the amount of traffic into the isolation room and therefore prevent possible cross contamination associated with carpets. 6. Theatre disposable shoe covers were used in order to prevent the spread of spores. 7. Patient was barrier nursed for entirety of stay by one nurse who had no other patient caseload, 8. Advice gained as to whether there was any disposable footwear the ward could use as entering the patients room on carpet and then re entering the ward. No disposable footwear found. 9. Physiotherapists saw the patient last on their daily list. Care and service delivery problems 1. Having a single nurse from the ward to look after the patient could have led to issues with staffing levels. 2. Only one episode of loose stool was indicated as being offensive so second sample was sent however this was not labelled correctly. 3. Difficult to effectively decontaminate the isolation room because of carpet flooring. Contributory factors 1. Antibiotic treatment Iv cefuroxime 750 mg 14/03/12 at 13.20 14/03/12 at 21.20 15/03/12 at 03.20 2. Query medical treatment in French hospital and in Bushy Spires but no dates nor antibiotic usage is documented.
Root causes 1. Use of broad spectrum antibiotics Lessons learned: Recommendations Education and training to reinforce use of the Bristol stool chart. Education and training on C.difficile. Give patient Information leaflets on C.difficile. Label samples as per protocol Audit hand hygiene compliance within the ward at least weekly when there is a Patient with C.difficile /diarrhoea. In order to maintain constant C.difficile awareness the Trust must continue to reinforce vigilance and awareness of risks that are associated with C Diff and to promote antimicrobials stewardship Disposable footwear for PPU could be implemented for infected patients or have the carpets removed. Arrangements for shared learning The report will be reviewed and an action plan will be implemented and monitored by the Clinical Governance Committee. Ward education regarding infection control and liaise with the infection control nurse regarding training. Distribution list Infection Control Committee Clinical Governance Committee. Clinical Risk Outcome Panel Appendices Author Georgina Whorlow Michelle Bozier Zama Khumalo Job title Staff Nurse Ward sister ICN Date 02/05/2012 09/05/12
Appendix 1 RCA Tools Templates Fishbone Patient factors: History of having received various treatment in France and in Bushy but no documentation on antibiotics usage Staff factors: Nil identified Task factors: Nil identified Communication factors: No documented history of previous antibiotic usage for patient Team + social factors: A nurse had to be designated to look after the affected patient Problem or issue C.difficile infection on a generally healthy patient Education + Training Factors: Use of the Bristol stool chart. Information about C. difficile to patients and staff. Equipment + resources: Decontamination issues as the room is carpeted Working condition factors: Designating a single nurse to one to one the patient affected staffing levels on the ward Organisational + strategic factors: Use of cefuroxime x 3 doses for prophylaxis as main cause of CDI
Appendix 2 ROOT CAUSE ANALYSIS ACTION PLAN Clostridium Difficile on Ian Monro Ward Risk Description Use of iv cefuroxime X 3 doses for prophylaxis. Controls Currently In Place Antimicrobials policy Royal Free Hospital Infection Service Consequ ence (C ) 1 Insignific ant 2 Minor 3 Moderate 4 Major 5 Catastrop hic Likelihoo d (L) 1 Rare 2 Unlikely 3 Possible 4 Likely 5 Almost Certain Risk Rating (C X L) 5 4 High Action Description The Trust has to make an informed decision on antibiotic prophylaxis i.e.use of iv cefuroxime X 3 doses for prophylaxis must be urgently reviewed. Start Date 2012 Anticipated Date Of Completion June 2012 Designated Lead DIPC Risk Rating after actions complete ( C X L including score) 5x 4 = 20 Progress Action Taken For each action state whether it is: Completed Ongoing To be discussed in relevant committees. July 12 Discussed at The antibiotic of choice must be effective but less likely to predispose patients to C.difficile infection. Continue to promote antimicrobials stewardship constantly. 2011 Ongoing Pharmacy/ Microbiology / ICN Ongoing Audit usage of antimicrobials at RNOH 2012 Not yet complete Pharmacy/ Microbiology In progress
Formulate Antimicrobials Steering Group Jan 2012 Not yet complete Pharmacy/ Microbiology/ DIPC Environmental Decontamination issues. Affected patient was in a carpeted isolation room High risk of infection spread (C.difficile spores) which could have resulted in cross Contamination and possible outbreak Cleaning and decontamination policy, DH guidance 4 4 High Carpets are a great infection control risk and must removed from all clinical areas and be replaced with washable flooring. 2011 Director of estates and facilities, the ICC, DIPC 4x 4 = 16 The issue of carpets has been highlighted with the DIPC, and health and safety committees. Promote constant awareness on issues related to C.difficle Training and education 3 3 Moderate Continuous Training and education of staff on these issues and aim to achieve sustained compliance. Reinforce use of stool charts as well as Bristol stool charts and proper stool sample collection and labelling. 2012 2012 ICN/Micro 3x 3 = 9 Staff and patient information leaflets and posters are now available across RNOH. Annual update training session on various IC topics including C.difficile is ongoing. Adhoc training at ward level is arranged with the ICN as necessary.