Hospital ward/clinical Area Date Trigger Tool Commenced Date Trigger Tool Closed Person closing the CDI Trigger Health Protection Scotland V2.0 November 2011
A CDI Trigger is the point at which the Infection Prevention & Control Team (IPCT) will investigate to determine if infection control systems in a given location are making patients more vulnerable to CDI. A CDI trigger is the number of new CDI cases, in a given time period identified as having an association with a specific clinical area. A CDI trigger should be set for all clinical areas including in community hospitals. It should be set by the IPCT and known by the clinical team on every ward. A CDI trigger may be reached as a consequence of either natural variation in the number of cases or because the system of infection prevention and control, including antibiotic prescribing, is resulting in making patients more vulnerable to CDI. Only by investigating CDI triggers can it be determined if systems need to be changed. A trigger is not synonymous with the term outbreak. A CDI trigger is a more sensitive point at which the IPCT becomes concerned that there may be a systematic cause for the increase in cases and decides intervention is necessary to ensure patient safety. Objectives for the CDI Trigger Tool: To enable the IPCT to determine if the CDI trigger is real, or the result of natural variation in the number of CDI cases. To enable IPCTs to promptly identify any areas for improvement in the care of patients, the environment or antimicrobial prescribing that are making patients more vulnerable to CDI or increasing the risk of CD cross-transmission. To create a culture and system that minimises the risk of patient susceptibility to CDI and CD crosstransmission. Senior Charge Nurse (Ward Manager) Responsibilities Recognise and report clinical (cases) triggers to the IPCT and medical colleagues as per local reporting systems Lead and complete the clinical actions if this trigger is considered real Report using Risk Management Reporting systems if resources to meet patients safety needs are unavailable Ensure that there are sufficient staff available to deal with patient care needs Clinicians Confirm that the clinical care of patients is compliant with local/national guidance, including observations, specialist referrals and antibiotic therapy Report to IPCT directly if they have concerns regarding infection control and CDI prevention If a pharmacist is unavailable, e.g. out of hours, then the medical staff with advice from the microbiologist should review the antimicrobial prescribing Infection Prevention & Control Team (IPCT) Set triggers and identify immediately through local surveillance when a trigger occurs Work with the senior charge nurse and clinicians to complete this trigger tool and support quality improvements to facilitate safe patient care Identify if CDI triggers are activated due to system errors amenable to correction or reflect natural variation Pharmacist Review the antibiotic regimens of all patients in the ward ensuring this is consistent with local policy Provide recommendations for prescribing to reduce the risk of CDI to patients Report triggers to the Antimicrobial Management Team General Manager Ensure the ward team has the resources to provide a safe patient environment HPS. V2.0 November 2011 page 2 of 9
Day 0 Date: / /. (the date the trigger was identified) Location: Hospital and Clinical Area Assessment of the CDI trigger to be completed by the IPCT What is the trigger threshold for this ward? (e.g. 2 CD new toxin positives in 30 days) What is the number of cases prompting this CDI trigger? This could be higher than the trigger threshold if more than 1 case is identified on the same day). Include a run chart or SPC if this more helpfully describes the context of the situation. Assess the patients data to confirm if the CDI trigger is real: Is the number correct? i.e Has the CD acquisition been in other areas? Are there any recent changes in the patient population, e.g. change in the patients cared for (and their CDI risk)? Situation Report To be completed by IPCT What is the Hospital Infection Incident Assessment Tool (HIIAT) for this incident? (NB inform SGHD and HPS if HIIAT Red or Amber). Red Amber Green Web link to HIIAT Today, how many patients on this ward have CDI (i.e. are symptomatic and have had a C. difficile toxin positive test)? Today, how many other patients have symptoms that could be CDI are on the ward? Today, how many staff are symptomatic and/or diagnosed with CDI? In the last 30 days, has CDI been recorded on any patients LINK to CDI Severe Case Tool Page 6 death certificates, or has the CDI Severe Cases Investigation Tool been completed? Who is the lead IPCT member for this trigger? Who is the Senior Charge Nurse/Ward Manager for the ward? Is the trigger confirmed? Yes or No circle 1 If the CDI trigger is considered to be natural variation Signature: STOP here and sign to say this the CDI trigger is not real If the CDI Trigger is real, then complete all Day 0 actions HPS. V2.0 November 2011 page 3 of 9
Day 0 Date: /./. (the date the trigger was identified) Immediate Clinical Actions to be completed once the CDI Trigger is confirmed as real Nurse in charge to complete in conjunction with IPCT Are all the patients with CDI isolated in single rooms with en suite facilities and a clinical wash hand basin? If no, why not If there are no single rooms available are all patients with CDI cohort nursed, with en suite facilities or individual commodes? If no, why not Are the doors to all isolation rooms/cohort areas kept closed? (A risk assessment should be done to confirm safety of keeping If no, complete risk assessment and doors closed) close doors if safe to do so Have faecal specimens been sent from patients who have symptoms suggestive of CDI? If not, send specimens Are there daily clinical assessments recorded for all patients with CDI? (NB all severe cases of CDI require the use of the If no, ask for severity assessments to Severe Case Investigation Tool Page 6) be completed now. Has a request for C. difficile culture been submitted to the Scottish C. difficile Reference laboratory in the case of a) severe disease, b) suspected outbreak? Have all patients with symptoms been assessed for CDI specific antibiotic treatment today? Consider closing the ward or bay area to admissions if: State the outcome of any closure or There are inadequate facilities/environment to ensure the restriction of ward routines decisions safety of patients. There are insufficient staff to provide a safe patient environment. Patients with CDI cannot be safely separated from patients who do not have CDI. If ward is closed, consider allocating staff specifically to care for the CDI patients or the patients without CDI. If no, why not Avoid unnecessary transfer of patients with CDI out of the ward unless medically necessary. If necessary, prior to the patient s transfer, the staff in the receiving ward must be aware of the infection control precautions required. (Document when done) Use this space to document the rationale for any closures, restrictions or non closures: HPS. V2.0 November 2011 page 4 of 9
Day 0 Date: /./. (the date the trigger was identified) Immediate Infection Control Check of Equipment, Environment and Practices Nurse in charge to complete in conjunction with IPCT Confirm done Soap and water must be used for all hand decontamination when caring for symptomatic patients. Do not use alcohol based hand rub alone. Personal protective equipment (PPE), disposable gloves and plastic aprons must be used by all staff when entering a cohort area or isolation room. PPE is removed and hands washed before and after leaving cohort area or an isolation room. Clean and then disinfect all commodes, toilets including isolation areas with detergent and 1000ppm available chlorine. Establish a cleaning regimen of the cohort/isolation area and all equipment in the area (detergent and 1000ppm available chlorine). Clean and then disinfect all frequently touched surfaces throughout the ward with detergent and 1000ppm available chlorine. Establish twice daily decontamination of all frequently touched environmental sites and surfaces which includes cleaning and disinfection with detergent and 1000ppm available chlorine. Dedicate care equipment for the specific use of patients with CDI, e.g. blood pressure cuffs, washbowls, stethoscopes and thermometers. Declutter the ward and the clinical environment. Consider the possibility of airborne dissemination of C. difficile spores, e.g. by the use of fans or other activities that increase air turbulence. Remove fans if considered a risk. If ward is closed to admissions, place a notice on ward door. Immediate patient care assessment Nurse in charge to complete All patients with CDI: Confirm done Have an up to date stool chart, with all stools passed recorded and described, e.g. using the Bristol Stool Chart. Have had their medication reviewed specifically the use of antibiotic, proton pump inhibitor and laxative therapy. Are on appropriate CDI specific antimicrobial therapy with daily assessment of severity of CDI. Have had their clinical condition reviewed today including referral to ID physicians or surgeons as per the national/local guidance Are aware of their CDI status (or their relatives if appropriate), and the actions being undertaken by the ward team regarding their CDI treatment, and any restrictions / precautions to prevent ongoing cross-transmission. This is documented in their case notes. Patients (or relatives) have access to written information on CDI including prevention and control measures. HPS. V2.0 November 2011 page 5 of 9
Day 0 Date: /./. (the date the trigger was identified) Immediate Patient Antibiotic Assessment Pharmacist to complete Confirm done Review all antibiotic prescription charts for compliance with local antibiotic policy. This must be communicated to clinical staff. Comment on the use of antibiotics on this ward: Immediate Knowledge and Communications Check Nurse in charge to complete with IPCT Confirm done Inform all clinical staff on duty that there is a CDI trigger on this ward. Inform all members of staff on the ward - including domestic staff - of the situation, the organism, how it spreads in the ward environment and what they need to do to further reduce risk to patients, to themselves and to co-workers. Also inform them of their part in monitoring for deterioration in the situation e.g. changes in cleaning frequencies and the need to add disinfectants to the decontamination regimens. Identify any learning gaps in ward staff with regard to the prevention of CDI and antimicrobial prescribing, care of patients with CDI and infection prevention and control. Ask all members of the clinical team to consider their practice and identify any actions or inactions that could have contributed to the increased number of CDI cases, and discuss this with the clinical leads or the IPCT. Inform the following people of the CDI trigger and the HIIAT grade: All Consultants with patients on the ward Antibiotic pharmacist Microbiologist HAI Lead Local Management as specified in Local Governance Reporting Procedure e.g. Risk Manager, Bed Manager, General Manager, Communication Representative and Health Protection Team HPS (Scottish Government if HIIAT is Amber or Red) The patients (or relatives) with CDI are informed of the situation and given written information on the control methods. This is documented in the case notes Visitor Access Considerations Depending on the size of the situation, give consideration to restricting the number of visitors. NB if patients with CDI deteriorate to having severe disease, o Consultants in microbiology and infectious disease may need to be informed in line with national guidance. o Severe CDI case investigation tool should be completed: http://www.hps.scot.nhs.uk/haiic/ic/publicationsdetail.aspx?id=44042 HPS. V2.0 November 2011 page 6 of 9
Day Date: /./. (the date the trigger was identified) Daily CDI check by the clinical and IPCT Complete each day until CDI Trigger is resolved Have any new patients/staff been confirmed with CDI today? How many patients on the ward have CDI? Is this an increase/decrease or unchanged from yesterday? How many patients have diarrhoea but do not have a C. difficile toxin test result? Is the segregation of patients with CDI in this clinical area sufficient to prevent CDI crosstransmission? Have isolation/cohort procedures been effectively established? Have the isolation/cohort areas been supplied with dedicated care equipment, e.g. blood pressure cuffs, stethoscopes and thermometers? Are doors to the isolation/cohort areas kept closed (or daily closure risk assessment completed)? Are contact precautions established: use of PPE, hand-washing with soap and water? Have the clinical assessments of all patients with CDI been recorded today and as a consequence of this review appropriate referrals/actions been taken? Is the unnecessary movement of patients outwith the isolation/cohort area restricted? Are there sufficient staff on the ward to provide a safe patient environment? Are staff on the ward aware of the control measures and the restrictions that are in place? Are any learning gaps being addressed? Are patients and/or their relatives aware of their CDI status and the control measures required? Is the environment clean and free from clutter? (check fans are removed or restricted) Has a routine of twice daily decontamination of frequently touched sites and surfaces with detergent and 1000 ppm available chlorine been established? When discontinuing isolation of a CDI patient (i.e. as a minimum they are symptom free for 48hrs and bowel movements have returned to normal), the procedure is treated as a transfer that is providing the patient with a clean bed, clean over bed table/locker. (Thus allowing for thorough decontamination of their present bed and environment with 1000 ppm available chlorine). Is all equipment on the ward visibly clean and in a ready for next-patient use condition? Is the ward equipped with adequate necessary supplies e.g. PPE? Are all commodes, including those in the isolation/cohort facilities, clean and decontaminated with detergent and 1000 ppm available chlorine? Has antibiotic prescribing for all patients been reviewed today for compliance with policy? Is the movement of staff restricted between isolation/cohort areas and other areas not affected by CDI including other wards? Based on the above information: (IPCT to confirm and communicate this) o Is there any need to change to the open/closed status of the ward? o Is there any need to change the HIIAT? Are daily CDI checks still necessary? If yes, continue with daily assessments, if no proceed to next section: Lessons Learned and Changing Systems. IPCT to advise on any terminal clean procedure HPS. V2.0 November 2011 page 7 of 9
Date: /./. Complete once all investigations are concluded Learning Lessons and Changing Systems What could have contributed to the CDI Trigger? Charge Nurse and IPCT to complete - Action Plan Template overleaf Were any deficiencies in antibiotic prescribing identified If yes, list the systems changed to rectify that could have contributed to patient susceptibility? this and reduce the risk of recurrence Were there any deficiencies in practice that could have contributed to cross-transmission or delayed detection of this trigger, e.g. o Delayed or non-isolation o Delayed sending of specimens o Inadequate contact precautions use of PPE o Use of alcohol based hand rub alone rather than soap and water o Excess patient movement Were any deficiencies in the maintenance of a safe patient environment identified, e.g. o Cluttered environment o Inadequately cleaned environment o Inadequately cleaned equipment, commodes, washbowls o Insufficient single-rooms to isolate all patients requiring contact precautions o Extensive use of fans Were there any other factors that could have contributed to the CDI trigger identified? If yes, list the systems changed to rectify this and reduce the risk of recurrence If yes, list the systems changed to rectify this and reduce the risk of recurrence If yes, list the systems changed to rectify this and reduce the risk of recurrence What other preventive measures could be instigated, e.g. o More regular use of the CDI checklist o Instigating the CDI Cross-transmission bundle Send completed form to: (Include AMTs in distribution) HPS. V2.0 November 2011 page 8 of 9
ACTION PLAN FOLLOWING A CDI TRIGGER This should be completed following the lessons learned on the previous page Action to minimise the risk of recurrence Who will do When to be Confirmed this completed complete HPS. V2.0 November 2011 page 9 of 9