Introduction purpose: West Hertfordshire Hospitals NHS Trust Reducing Clostridium difficile infection Action Plan 2012-2013 [Updated 19/3/13] Item 37/13 This action plan has been developed by West Hertfordshire Hospitals NHS Trust (WHHT) in conjunction with PCT HPA to ensure that patients who are diagnosed with Clostridium difficile infection are managed appropriately through the appropriate management of known cases the Trust reduces the risk of transmission of infection to patients. WHHT has a zero tolerance to avoidable cases ensures that with every case diagnosed a systematic review of the patient journey is undertaken to identify learning for the trust or other providers. Sharing lessons through the Whole Systems HCAI working group. This action plan is based on a WHHT assessment of the robustness of processes in place. WHHT has a PCT contracted ceiling of 33 cases of Clostridium difficile (C.diff) toxin positive for 2012 2013. The implementation of the action plan will be monitored by the Infection Control Committee. Status: Review Date: Ratified (date): 18 March 2013 Ratifying Committee: Infection Control Committee 1
West Hertfordshire Hospitals NHS Trust Reducing Clostridium difficile infection Action Plan 2012-2013 Priority /No Clostridium difficile Toxin (CDT) positive cases - Aim to ensure that cases (> day 2) do not exceed ceiling of 33 for April 2012 March 2013 1. To monitor cases of CDT 1.a Surveillance - All positive CDT results are communicated to relevant Trust staff - Isolation compliance monitored on a daily basis disseminated weekly to relevant Trust staff monthly to the Infection Control Committee (ICC) - All CDT RCAs discussed at the Trust s bi-weekly local Healthcare Acquired Infection (HCAI) meeting - All confirmed CDT samples are sent for ribotyping. The presence of the 027 strain appears to be much higher within West Herts than in other areas. Infection control team continuing A list of all stool specimens that take the shape of the container are reported daily to the by the laboratory these areas are contacted to identify if the patient is isolated. January compliance is 78% all noncompliance is challenged incident forms requested when appropriate discussed at the Infection Control Committee meeting (ICC). Weekly HCAI meetings from the end of February 2013 due to increased incidence of C.diff. Rybotype results are included in all C.diff RCAs shared with the PCT Director of Public Health. 1b. Outbreak of CDT Definition: Two or more cases with onset within seven days of each other, or three or more cases with onset within 28 days of each other, occurring in a single ward or bay of beds within a ward. - Implement the Trusts outbreak policy Infection control team, Matron, Ward sister, Medical staff, continuing Two C.diff outbreaks involving a total of eight patients have been identified reported at WHHT since April 2012. The Trust s outbreak policy was followed no further cases were identified in these areas. RCAs were undertaken on all cases cross infection did not appear to be implicated. - Report as a serious incident The recent C.diff outbreak on the Care of the Elderly Unit has resolved. 2. Prevention of C.diff disease 2a. Ward Rounds - ward rounds - Twice weekly board rounds in the Acute Admissions Unit Microbiologist, Pharmacist, During all ward rounds, antimicrobial therapy is reviewed, challenged changed where appropriate. 2
/No - Daily microbiology ward rounds to review complex cases - To ensure antibiotic use is appropriate, limited spectrum limited duration ADIPC, Ward consultant Recent audit Croxley/Sarratt showed 100% compliance with guidance s. 3. Best practice in management of symptomatic CDT 2b. Probiotics prescribed for all medical patients >65 years old 2c. All patients with diarrhoea must be isolated within two hours of the first episode unless not considered of an infectious nature. 2d. Weekly h hygiene / Lewisham audits to be undertaken in in-patient areas 3a. Suspected cases of CDT Manage in line with policy: - Maintain accurate stool chart - Isolate in a single side room within two hours of first episode - Stool samples to be taken promptly following risk assessment by senior doctor - Review medication take action as appropriate 3b. Confirmed cases of CDT - Maintain accurate stool chart - Patients to be transferred to ring-fenced isolation rooms - Root cause analysis (RCA) to be Clinicians, Ward Nurses, Pharmacist, Infection control team, Medical teams, Pharmacist, Ward staff 31/3/13 19/02/13. Some patients have been refusing Probiotics as they do not like the taste. To increase compliance, flavoured probiotics drinks are now on order. Flavoured Probiotics are now available in the Trust as patients were refusing the plain drinks due to the taste. Pharmacy audits show that compliance has increased as a result. High risk patients who refuse probiotics should be made aware of the risk Occasions when rapid isolation is not possible, the ICN is contacted by the ward staff or bed manager for risk assessment allocation of side rooms. Incident forms completed when this is not possible. Still concerns about delays in isolation. Disciplinary actions are being considered.. Fidaxomicin is now used for patients who relapse do not respond to treatment. This is prescribed following advice by a consultant microbiologist.. Letchmore ward is no longer used as an isolation ward. All symptomatic patients who are C.diff positive are to be nursed in the six bedded isolation unit on AAU3. 3
/No undertaken on all confirmed cases of C.diff whether attributed as WHHT acquired (> day 2) or the patient has been an inpatient at WHHT in the previous three months. RCAs discussed at the bi-weekly HCAI meetings more frequently when necessary / increased incidence. - All RCAs to be discussed at the Trust s bi-weekly local Healthcare Acquired Infection meeting to discuss findings agree recommendations HCAI Group - d RCAs disseminated to relevant internal external agencies 3c. Timely detection - Bristol stool chart to be maintained on all patients within the Trust - - Stool specimens to be sent on all patients with diarrhoea (takes the shape of the container) following risk assessment decision by senior doctor or Nurse. Infection control team, Matrons, Senior Sisters Senior Sisters, Senior Clinicians Bristol stool chart in use across the Trust. Flowchart embedded within the Trust as a tool to guide appropriate stool sampling. Flowchart amended 8/2/13 to enable the nurse in charge to undertake risk assessments for the appropriateness of taking stool specimens. - Side room list to be available to the on a daily basis to enable risk assessment for isolating patients appropriately - All new patients with diarrhoea to be reviewed by the ICT Bed Management, Infection Control Nurses Infection control team Ward staff inform the Infection Control Nurses () of any symptomatic patients not highlighted on the side room list provided by the bed management team - Symptomatic patients to be nursed in source isolation within two hours of the first episode of diarrhoea Senior Sisters, Bed Management, Infection Control Nurses Policy in place which the staff are aware of. If side room not available, bed managers contact an ICN to undertake a risk assessment to prioritise side room occupation. A flow chart has been developed for bed managers ward staff to use to aid prioritising isolation outof-hours when an ICN is not available. 4
/No 3d. Treatment Suspected or confirmed cases of CDT: - Review medication discontinue high-risk medication if appropriate - Appropriate antibiotic therapy to be commenced in line with Trust policy Ward clinicians, Microbiologist, Pharmacist All new cases are discussed with the microbiologist to ensure the patient is on appropriate medications treatment. 4. To monitor review antimicrobial prescribing practice Publishing issue guidance 4a. Policies Practice - policy to reflect best practice, is appropriate, limited spectrum limited duration. - flash card readily available for all medical staff - use discussed at the Trust s bi-weekly HCAI meeting inappropriate use challenged. - There is increasing concern that C.diff may be associated with the use of Coamoxiclav - CJ to circulate to all consultants. 4.b Audit - audits undertaken monthly presented to the ICC - Proton pump inhibitor usage audited monthly presented to the ICC - Weekly audits to review who is prescribing Probiotics ( Doctor or Pharmacists) - Weekly audit of antimicrobial PPI use across the medical division. Microbiologist, Pharmacist HCAI group Colin Johnston Pharmacist Nursing staff Microbiologist, Pharmacist Monthly 31/3/13 31/3/13 Antibiotic guidelines in date Point Prevalence Survey on Use undertaken in October 2012 by Trust Pharmacists. 35% of patients were prescribed antimicrobials which is similar to the national reported data. Overall compliance to antimicrobial guidelines was 86% - this is an increase of 6% since 2010. Croxley/Sarratt audits completed set again on 05/03/2013. Antibiotic use has been discussed at the local HCAI meeting it was not recommended that we have a change in the antibiotic policy however we do want to emphasise best practice reducing the use of broad spectrum antibiotics, particularly multiple courses ideally reducing the use of Co-Amoxiclav. This will be undertaken through the continued education, daily ward pharmacy visits, weekly antimicrobial rounds twice weekly board rounds within the Acute Admissions Unit (AAU). Monthly antimicrobial usage is presented to the monthly ICC for discussion monitoring. Results from January show reduction in usage of both Augmentin & Tazocin Current antibiotic review is to consider whether we can reduce the use of Co-amoxiclav 5
/No promote the use of Penicillin, Amoxicillin Doxycycline. 5. Empower staff to be pro-active rather than re-active 5a. Medication - PPI usage to be reviewed on admission discontinued when / if appropriate. - A repeat point prevalence survey (PPS) is to be undertaken February 2013 - Green dot to be placed on the front of drug chart as an alert to indicate that the patient is at increased risk of developing CDAD as prescribed a PPI - Probiotics to be prescribed for all medical patients over 65 years of age who are prescribed antibiotics. 5b. Clinical Activity - Daily ICN presence on the wards - All staff to challenge poor infection control practices - Each clinical area to have infection control link nurse/person (ICLN/P) - Infection control notice board to be maintained updated in all clinical areas. Clinical Team, Pharmacist, Ward Nurses All Trust Staff 28/2/13 A PPS on antimicrobial use was undertaken by the Trust s pharmacists in October 2012. PPI usage was reviewed during this survey a total of 53 patients were prescribed PPIs. Half of these patients had reason for use documented, half of which were appropriate. PPIs continue to be monitored on the weekly antimicrobial ward rounds daily antibiotic stewardship round. The PPS is normally undertaken annually, however due to poor compliance a repeat is in the process of being undertaken. The use need for review of PPIs are also included in the C.diff training sessions described in section 8. The results of the repeat survey will indicate the effectiveness of the education programme. On-going education for both nursing medical staff continues within the clinical setting. Staff continue to challenge poor h hygiene dress code including bare below the elbows. Weekly h hygiene observational audits are undertaken in clinical areas. 6. Environmental cleanliness 6a. Environment - To use a detergent/disinfectant cleaning agent with sporicidal properties - Rapid response domestic team to be available 24 hours a day to ensure environmental cleanliness can be Medirest, Ward Staff, Matrons, Head of Nursing for Medicine, Results show receives 100% compliance but not all wards send returns. This is being escalated ICLN/P link meetings held bi-monthly. Chlorclean used for all decontamination purposes in the clinical areas. Rapid response team is contactable via bleep. Records kept by Medirest of all areas cleaned. 6
/No maintained to the appropriate stards - 12 week rolling programme for deep cleaning in-patient areas - 120 bedded Acute Assessment Unit (AAU) to be deep cleaned - Deep clean required following termination of isolation / transfer of an infectious patient. - Evidence required that deep cleans have been undertaken 31/12/13 AAU deep clean completed 20/11/12. Three deep cleans are planned throughout 2013. Commenced 9/2/13. Cleaning is once again being undertaken at night so that patients can be transferred to day units overnight while the areas are deep cleaned utilizing the hydrogen peroxide vapour machine. Terminal / deep clean monitoring form in use across the Trust documenting the area, date, times, type of clean undertaken if the hydrogen peroxide machine is used. -Deep clean to be undertaken on Sarratt, Croxley Stroke wards following the increased incidence in February. Matrons, Medirest 15/4/13 Operational plans commenced following extraordinary meeting 8/2/13 - Ward areas to be de-cluttered 6b. Equipment - Commodes to be dismantled each time they are used to enable thorough cleaning - Signed green tape to be put on each commode once decontaminated to identify that it has been decontaminated - All commodes in AAU to be checked counter-signed by a ward sister after staff have cleaned them - Chlorclean to be used in all clinical areas for decontamination of equipment. - All equipment is to be decontaminated after each patient use as per manufacturer s instructions. - to check all commodes weekly to monitor cleanliness Nursing staff Matron Senior Sisters 21/2/13 31/3/13 Agreed at meeting 14/2/13. To commence immediately Commodes audited weekly more frequently if soiled commodes are identified External audits undertaken to monitor cleanliness appropriate use of: commodes, macerators, h towels, soap, gel Chlorclean Commenced weekly audits 13/2/13 7
/No 6c. Monitoring - Monthly Patient Environmental Action Team (PEAT) audits to continue - Regular walk-abouts with members of the Infection Control Team, Medirest Board Directors to be undertaken - Environmental audits to be undertaken during the annual Think Clean Week - Annual ICNA environmental audits to be undertaken in all clinical areas - All members of the executive team to undertake walk-abouts monthly including audit commode monitoring with ADIPC/ICN Patient s Panel, ADIPC,, Medirest, Matrons Estates, Facilities Executive team ADIPC Audits continue as planned. Repeat visits undertaken by Medirest to areas of concern. Audit results are disseminated to relevant staff for their information auctioning as appropriate. Dates currently being arranged. 7. Effective communication to staff, patients the public. 7a. Staff - Relevant up-to-date infection control documents information to be readily available on: Trust Intranet site Infection control notice boards - Relevant information to be e-mailed to appropriate Trust staff in a timely manner - Relevant posters to be displayed as appropriate - Bi-monthly board report annual report to be produced for the Trust Board. - E.mail to be sent to all WHHT users reminding them of the importance of maintaining optimal infection control practices - Weekly E-nuggets to be sent to all Trust staff with relevant infection control information ICT Chief Executive ADIPC, Communications Bi-monthly annually 18/2/13 Effective communication remains an integral role of the ICT Patient information leaflets readily available in clinical areas. These are reviewed by Patients Panel prior to distribution to ensure clarity... Board reports provided bi-monthly annually ADIPC communications department met 15/2/13 to organise the messages to be sent. 7b. Public / Patients - To attend the Annual General Meeting ICT, Trust An infection control st is displayed at the AGM the infection control nursing team is 8
/No (AGM) - Patient information leaflets to be readily available - To be transparent with all surveillance data - ICN to be available to speak to patient visitors to allay concerns answer questions Communications Team, available to discuss relevant issues with the public are able to answer queries address concerns they may have in relation to infection prevention control. 8. Training 8a. Infection Control training to be provided: - Induction for all staff - Annual matory training for all staff - Two hour C.diff study sessions for relevant clinical staff - Six day infection control awareness course for qualified staff - Infection control study days - Planned ad-hoc ward based C.diff training sessions - All staff on Sarratt, Croxley Stroke wards to be re-trained in all aspects of C.diff by the through ward-based training. - All other relevant nursing staff to receive ward based training as above - All new staff to receive ward-based training on pertinent issues relating to C.diff 9. Up-to-date policies to be readily available to all Trust staff 8a. Relevant policies in place following national guidelines: - C.diff - Isolation - Outbreak - H hygiene - Decontamination Matory / Induction: All WHHT staff And continuing 30/9/13 31/12/13 Matory training is available in classroom sessions or via an e-learning package. An annual six day course, bi-monthly single study days quarterly C.diff sessions are planned for 2013. Dates to be confirmed when rooms available for booking. The two hour C.diff study session planned for 5/2/13 was cancelled due to lack of delegates.icn training on the wards as much as possible Training complete. Night staff must attend a C.diff training session to ensure they receive training. obtaining list of all staff members in order to cross-reference those trained. Director of Nursing arranging for all new staff names to be routinely sent to for followup ICT All policies up-to-date available to all staff on the Trust Intranet site. 9
/No 10. Ensure there are robust systems in place for patient transfers 10a. - Discharge check-list to be accurately completed prior to transfer from WHHT - No patients are to be transferred from WHHT if they are showing signs of diarrhoea or loose stools Ward staff, Discharge Coordinators Transfer check-list has been amended to include a prompt for staff to ensure they do not proceed with a transfer on any patient with loose stools or diarrhoea. It has been identified through RCAs that this is not always adhered to. Lack of compliance resulting in an inappropriate transfer is fed back to relevant senior staff to ensure future compliance. 11. To remain within the annual trajectory 11a. - To remain within the trajectory of 33 - To be compliant with policies processes in place - To share with executive team via DSG. Health Authority by the Provider meetings, PCT via quality meetings HCAI meetings. No Medical Director/DIPC 31/3/13 On going The Trust has exceeded its annual trajectory currently has 46 hospital acquired infections. Presented to the Board via High Risk Entry on the Trust Board Assurance framework. Recent review at the Integrated Risk Clinical Governance Committee which is a sub-committee of the Board. This was presented at the Trust Board Meeting in January 2013. The Board Executive team are fully aware of the severity of the problem. Extra-ordinary meeting convened 8/2/13 continues daily following three hospital acquired C.diff infections in February. Actions agreed encorporated within this action plan. 2 meetings with PCT & HPA held 4/3/13. The Herts Valleys Clinical Commissioning Group was invited to the Trust to review assist in reducing the incidence of C.diff in the Trust. A West Herts Economy Outbreak meeting was held 4/3/13 further meetings will follow. The Director of Nursing / DIPC from Bedford Hospital visited the Trust 15/3/13 following an invitation from the CEO. 10
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Terminal / Deep Clean for all Patients with Ward Name Diarrhoea, C.difficile or MRSA Side room / Bed space Date Time requested Bed already made? / No If 'yes', nurse to remove bed linen If 'not removed', time requested to return Time clean started Time clean finished Removed / Not removed Sterinis machine used? / No Curtains changed? (Must be changed unless Sterinis machine used Domestic's name Nurse's name Nurse's signature / No 13