Approved by: Clostridium difficile Infection (CDI) Vice President and Chief Medical Officer Corporate Policy & Procedures Manual VI-8 Date Approved August 22, 2016 September 16, 2016 Next Review (3 years from Effective Date) September 2019 Purpose To provide guidance for the management of patients with Clostridium difficile infections (CDIs) in healthcare facilities. Policy Statement Covenant Health Infection Prevention & Control is committed to patient/resident/client¹ safety at all levels of the organization by supporting and promoting an environment that encourages infection prevention and control best practices in the care and management of patients with CDI. Applicability This policy applies to all Covenant Health facilities, staff, members of the medical staff, volunteers, students and to any other persons acting on behalf of Covenant Health. Responsibility All Covenant Health health care providers* are responsible for creating and sustaining an environment that supports an infection control program that effectively prevents transmission of C. difficile and healthcare-associated CDIs. Principles 1. Precautions Required & Background Contact precautions are required at all times and must be implemented immediately when CDI is suspected. The primary mode of transmission of C. difficile spores is via the hands of healthcare workers and by direct and indirect contact with contaminated equipment. C. difficile is a Gram-positive, spore-forming anaerobic bacillus that produces toxins that cause diarrhea and colitis. CDI is one of the most common and costly healthcare-associated infections, and can cause significant morbidity (i.e., pseudomembranous colitis) and mortality in infected patients. The primary risk factor for CDI is antimicrobial exposure. Therefore, effective antimicrobial stewardship can reduce CDI rates. Thorough cleaning of the hospital environment and patient care equipment is required to reduce spore contamination and incidence of CDI. 2. Hand Hygiene Guidelines Refer to Corporate Policy #VI-10, Hand Hygiene. Hand washing with soap and water must be performed after caring for patients with C. difficile infection. Alcohol-based hand rubs are ineffective against C. difficile spores. If a hand hygiene sink is not available at the point of care or hand hygiene is carried out at the patient/resident sink, there is potential for contamination of the ¹ Hereafter, all references to patients includes residents and clients. *See definitions
VI-8 Page 2 of 9 health care provider s hands. In this situation alcohol based hand rub may be used and soap and water hand wash should be performed as soon as an employee designated hand washing sink is available. 3. Patient Hygiene Acute Care: Linen must be changed daily for all patients on additional precautions. Continuing Care: Linen must be changed on shower/bath day and as needed. Acute Care: All patients on additional precautions must be bathed daily using soap and water or pre-packaged rinseless bathing washcloths (for example, Sage, etc.) Continuing Care: At a minimum, resident/client personal hygiene must be maintained daily, i.e., as needed pericare, daily fresh clean clothing, daily bathing with soap and water or pre-packaged rinseless bathing washcloths (for example, Sage, etc.) Patients must have access to appropriate hand hygiene agents, in particular, following pericare/ toileting, prior to meals, etc. 4. Personal Protective Equipment (PPE) Perform a Point of Care Risk Assessment (PCRA)* (see Related Documents section). Prior to every patient interaction, healthcare providers have a responsibility to assess the infectious risk posed to themselves and other patients, visitors and health care providers by a patient, situation or procedure. Routine practices must always be followed, in addition to contact precautions. PPE is single-use only. At a minimum, non-sterile gloves and an isolation gown must be worn when entering the patient s environment. When non-sterile gloves are used, hand hygiene must be performed prior to removing a pair from the box. 5. Communication of Additional Precautions Place a contact precautions sign on the door/curtain and have personal protective equipment outside the room. Communication of CDI status should be placed on the chart and care plan, or other appropriate location, in order to alert staff to use additional precautions, along with routine practices. Additional precautions must be followed by all persons entering the patient s room. Refer to sign on door for further information. Receiving unit/department/facility must be notified of the additional precautions required. 6. Accommodations Single room preferred; door may remain open. If a single room is unavailable, patients should ideally be at least two meters (6.6 feet) apart. If unable to keep patients two meters apart, separate patients
VI-8 Page 3 of 9 with the greatest available distance allowed within the room space. The patient with CDI must be placed on additional precautions with dedicated toileting facilities, i.e., commode chair or private bathroom, if available. If patients with CDI need to be grouped together (cohorted), this may only be done under the direction and approval of Infection Prevention & Control. When patients are cohorted, separate additional precautions must be maintained on each patient in the same room and with each patient encounter, including separate and dedicated toileting facilities. 7. Patient/Roommate Contacts If a new positive CDI patient is identified roommate contacts do not need to be placed on contact precautions unless roommate is symptomatic with unexplained diarrhea. 8. Equipment and Supplies Dedicated toileting facilities are required, i.e., separate bathroom or commode chair. Use single-use items whenever possible, or dedicate non-critical patient care items (i.e., blood pressure cuffs and stethoscopes) to a single patient when they are known to have CDI. Avoid use of electronic thermometers and other shared equipment, as equipment is known to become contaminated with C. difficile. When dedicated equipment is not possible, patient items must be thoroughly cleaned and disinfected between uses with hospital-approved disinfectant. Minimize supplies taken into the patient s room. 9. Waste and Laundry Acute Care: Soiled laundry bag/bin must be located inside the patient s room. Continuing Care: Soiled laundry bag/bin must be located as close to the point of use as feasible. Waste/garbage should be discarded into the general waste. Double-bagging for waste or laundry is not required unless the bag is leaking. Disposable meal trays are not required. Commodes and bedpans must be handled very carefully to reduce spread of C. difficile spores from the commode/bedpan to the environment. Spray wands in bathrooms must not be used. 10. Environmental Cleaning Thorough routine cleaning is required according to Environmental Services frequency schedule with hospital-approved detergent/disinfectant as per Covenant Health and/or facility policy/procedure. Notify facility Environmental Services to request a terminal cleaning of the room when precautions are discontinued or upon discharge or transfer of patient. Toilet brush must be dedicated and disposable.
VI-8 Page 4 of 9 11. Patient Transport and Movement Within Acute Care Site Patient should remain in room unless essential medical/diagnostic/ rehabilitative services must be performed. If patient leaves room: o does not need to wear gloves but must perform hand hygiene with soap and water, o should wear a clean hospital housecoat, or clean clothing. Alert receiving unit/department of patient s CDI status and that additional precautions are required. It is recommended that the patient be accompanied by a health care provider. Health care providers transporting the patient must wear a gown and gloves. 12. Resident Flow/Activity in Continuing Care Resident may leave room only if diarrhea can be contained, hand hygiene with soap and water is performed and resident is wearing clean clothes. Instructions/Assistance should be provided to resident and documented regarding hand hygiene following toileting and prior to leaving room. Resident participation in group/recreation activities should be restricted if unable to contain diarrhea and perform hand hygiene. Resident transfer to another facility, or attendance at outside appointments should be avoided unless medically necessary if resident does not meet the criteria for leaving their room. 13. Patient/Resident Transport and Movement Outside Facility Information about the patient s CDI status and required additional precautions must be communicated directly to transport personnel and staff at the receiving site. If patient/resident is attending an appointment, request the patient/resident be seen promptly so minimal time is spent in public waiting areas. 14. Testing for CDI Routine testing for C. difficile in asymptomatic patients is not recommended, including use as a test of cure. Test for CDI if bowel movements are unusual or different for that patient, and if there is no other recognized explanation for the diarrhea (for example, laxative use, adverse effect of other medication, etc.) Testing for CDI should only be performed on diarrheal (unformed) stools (i.e., stool poured into a container must conform to the shape of the container), unless ileus due to CDI is suspected. The presence of three or more unformed or watery stools in a 24-hour period or 6 or more watery stools in a 36 hour period which is new or unusual for the patient is sufficient indication to perform testing for CDI. If Clostridium difficile testing was recently performed, repeat testing will not be done within seven days. If symptoms persist despite a negative CDI test, please contact the attending physician.
VI-8 Page 5 of 9 15. Frequency of Testing for CDI Positive Cases Do not repeat testing for C. difficile as a test of cure if a patient has previously had a stool sample positive for C. difficile, unless symptoms resolved with treatment and then reoccurred after treatment. C. difficile toxin testing should NOT be used to evaluate for C. difficile 'clearance' or as a 'test of cure'. Testing in this scenario will create results that will be ambiguous and difficult to interpret. 16. Documentation Communication of CDI status should be placed on the chart and care plan, or other appropriate location (but not the patient s room door), in order to alert staff to use additional precautions, along with routine practices. Document all education provided to the patient and family regarding CDI, hand hygiene and personal protective equipment. Accurate documentation of stool consistency and frequency is required. In Acute Care, this information is mandatory and is reported to Alberta Health Services (AHS) Provincial Surveillance. Accurate documentation is essential when considering discontinuation of precautions (Appendix B). If documentation is not complete, this may delay discontinuation of precautions. For assistance with identifying stool consistency, refer to Bristol Stool Chart (Appendix A). 17. Discontinuation of Precautions Contact precautions may be discontinued after 48 hours of normal stool pattern. As per #10 Environmental Cleaning room must be terminally cleaned prior to discontinuation of precautions. Patient must be bathed or showered upon discontinuation of precautions. Emphasis should be placed on patient hygiene (refer to #3). Vigilance should be undertaken for relapse of C. difficile infection. Many patients are at high risk of relapse for disease. 18. Patient Teaching Patients are required to perform hand hygiene with soap and water after toileting and before eating. If patients are unable to mobilize to a sink, hand washing may be accomplished with a soapy wash cloth. All education provided to the patient/family must be documented in the patient record. Definitions Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act [Alberta] or the Health Professions Act [Alberta], and who practices within scope and role.
VI-8 Page 6 of 9 Health care provider means any person who provides goods or services to a patient, inclusive of health care professionals, staff, students, volunteers and other persons acting on behalf of or in conjunction with Covenant Health. Point of Care Risk Assessment (PCRA) - an evaluation of the risk factors related to the interaction between the health care provider, the patient and the patient s environment to assess and analyze potential for exposure to infectious agents and identify risks for transmission. Related Documents The following resources are available @ http://www.compassionnet.ca/page172.aspx Covenant Health Corporate Policy #VI-10, Hand Hygiene. Covenant Health Infection Prevention & Control Posters: Personal Protective Equipment Putting on (Donning) Personal Protective Equipment Detailed Taking off (Doffing) Personal Protective Equipment Detailed Clostridium difficile Covenant Health Infection Prevention & Control Additional Precaution Toolkits: Acute Care CDI Toolkit Covenant Health Infection Prevention & Control Outbreak Toolkits: Acute Care CDI Toolkit Covenant Health IPC Diseases & Conditions Table: Recommendations for Management of Acute Care Patients @ http://www.compassionnet.ca/page185.aspx Recommendations for Management of Continuing Care Residents @ http://www.compassionnet.ca/page1155.aspx Covenant Health Infection Prevention & Control Routine Practices: Point of Care Risk Assessment Covenant Health Infection Prevention & Control Information for Staff: Management of Clostridium difficile Acute Care Quick Reference for Charge Nurses Covenant Health Infection Prevention & Control Information for Patients, Residents & Visitors: Clostridium difficile Covenant Health Infection Prevention & Control Continuing Care Resource Manual: Clinical Care Clostridium difficile (CDI) Covenant Health Infection Prevention & Control Best Practice Guidelines: Patients/Residents on Additional Precautions Participation in Group Therapies: Occupational, Physical and Recreational
VI-8 Page 7 of 9 References 1. Alberta Health Services - IPC Surveillance Committee (2015). Clostridium difficile Infection (CDI) Surveillance Protocol. 2. Association for Professionals in Infection Control and Epidemiology Inc. (2013). APIC Implementation Guide: Guide to Preventing Clostridium difficile Infections. Retrieved May 15, 2015 from: http://apic.org/resource_/eliminationguideform/59397fc6-3f90-43d1-9325- e8be75d86888/file/2013cdifffinal.pdf 3. Bowling, J.E. (2014). Clostridium difficile infection and pseudomembranous colitis. In R. Carico (Ed.), APIC Text of Infection Control and Epidemiology. Retrieved May 15, 2015 from: http://text.apic.org/item-73/chapter-72-clostridium-difficile-infection-andpseudomembranous-colitis/all 4. Cohen S.H. et al (2010). Clinical Practice Guidelines for Clostridium difficile Infections in Adults: 2010 Update by the Society of Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control & Hospital Epidemiology, May 2010, 31 (5): 431-455. 5. Continence Foundation of Australia (2015). Bristol stool chart. Retrieved June 16, 2015 from: http://www.continence.org.au/pages/bristol-stool-chart.html 6. Dubberke, E.R. et al. (2014). Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. Infection Control, 35(6), 628-645. 7. Provincial Infectious Diseases Advisory Committee (2013). Annex C: Testing, Surveillance and Management of Clostridium difficile in all Health Care Settings. Retrieved May 15, 2015 from: http://www.publichealthontario.ca/en/erepository/pidac- IPC_Annex_C_Testing_SurveillanceManage_C_difficile_2013.pdf 8. Public Health Agency of Canada (2013). Clostridium difficile Infection: Infection Prevention and Control Guidance for Management in Acute Care Settings. Retrieved May 15, 2015 from: http://www.phac-aspc.gc.ca/nois-sinp/guide/c-dif-acs-esa/index-eng.php 9. Public Health Agency of Canada (2013). Clostridium difficile Infection: Infection Prevention and Control Guidance for Management in Long Term Care Facilities. Retrieved May 15, 2015 from: http://www.phac-aspc.gc.ca/nois-sinp/guide/c-dif-ltc-sld/index-eng.php 10. Public Health Agency of Canada (2013). Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings. Retrieved May 15, 2015 from: http://publications.gc.ca/collections/collection_2013/aspc-phac/hp40-83-2013-eng.pdf Revisions October 9, 2015 February 6, 2012 November 1, 2011 November 3, 2010
VI-8 Page 8 of 9 Appendix A: Bristol Stool Chart
Clostridium difficile Infection (CDI) Appendix B: Stool Chart/Bowel Record VI-8 Page 9 of 9