Hospital ward/clinical Area Date Trigger Tool Commenced Date Trigger Tool Closed Person closing the CDI Trigger Health Protection Scotland March 2014 Version 3.0
A CDI trigger is the number of new CDI cases, in a given time period and location which merits investigation by the Infection Prevention and Control Team (IPCT). The IPCT will determine if there are actions or omissions which are making the patients in the clinical area more vulnerable to CDI. A CDI trigger should be set for all clinical areas including 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 chance or because something in 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 or improved. 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 of the CDI Trigger Tool: To enable the IPCT to determine if the CDI trigger represents an infection control issue. 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. Ensure communication to all staff, including locums, bank and other staff who function within the ward. Ensure communication extends to patients, relatives and visitors as relevant. 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. Understand the epidemiology of the CDI trigger by using the Reference Laboratory, where required. 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. Version 3.0. March 2014 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 that could explain this increase, e.g. change in ward size? Situation Report To be completed by IPCT 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? If information on the CD strains involved in this trigger is required, contact the CDI Reference Laboratory and send strains for typing as advised. In the last 30 days, has CDI been recorded on any patients death certificates, or has the CDI Severe Cases Investigation Tool been completed? http://www.hps.scot.nhs.uk/haiic/ic/publicationsdetail.aspx?id=44042 Who is the lead IPCT member for this trigger? Who is the Senior Charge Nurse/Ward Manager for the ward? Is the trigger confirmed? If a trigger is confirmed what is the Hospital Infection Incident Assessment (HIIAT) for this incident? (NB inform HPS if HIIAT Red or Amber). http://www.hps.scot.nhs.uk/haiic/ic/publicationsdetail.aspx?id=43437 If the CDI trigger is considered to be natural variation STOP here and sign to say this CDI trigger is not real. Yes/No Red Amber Green Signature: If the CDI Trigger is real, then complete all Day 0 actions, overleaf HPS. Version 3.0. March 2014 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 Yes/No suite facilities and a clinical wash hand basin? If no, why not If there are no single rooms available are all patients with CDI Yes/No cohort nursed, with en suite facilities or individual commodes? If no, why not Are the doors to all isolation rooms/cohort areas kept closed? Yes/No (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 Yes/No symptoms suggestive of CDI? If not, send specimens Are there daily clinical assessments recorded for all patients Yes/No with CDI? (NB all severe cases of CDI require the use of the If no, ask for severity assessments to Severe Case Investigation Tool Link Page 6) be completed now. Has a request for C. difficile typing been submitted to the Yes/No Scottish C. difficile Reference laboratory in the case of a) severe disease, b) suspected outbreak? Have all patients with symptoms been assessed for CDI Yes/No specific antibiotic treatment today? Consider closing the ward or bay area to admissions if: There are inadequate facilities/environment to ensure the 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. State the outcome of any closure or restriction of ward routines decisions Yes/No If no, why not Avoid unnecessary transfer of patients with CDI out of the ward Yes/No 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. Version 3.0. March 2014 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 with an Infection Prevention and Control Nurse Confirm done Soap and water must be used for all hand hygiene 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 after leaving cohort area or an isolation room. Clean and then disinfect all commodes, toilets including isolation areas with detergent and 1000ppm available chlorine (av cl.) or a combined detergent/chlorine releasing solution containing 1000 ppm av cl. Establish a cleaning regimen of the cohort/isolation area and all equipment in the area (detergent and 1000ppm available chlorine or combined detergent/chlorine releasing solution containing 1000 ppm av cl.). Clean and then disinfect all frequently touched surfaces throughout the ward with detergent and 1000ppm available chlorine or combined detergent/chlorine releasing solution containing 1000 ppm av cl. Establish twice daily decontamination of all frequently touched environmental sites and surfaces which includes cleaning and disinfection with detergent and 1000ppm available chlorine or combined detergent/chlorine releasing solution containing 1000 ppm av cl. Dedicate care equipment for the specific use of patients with CDI, e.g. blood pressure cuffs, washbowls and stethoscopes. 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 an IPCT approved 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 CDI severity. Have had their clinical condition reviewed today including referral to gastroenterology physicians or surgeons or microbiologists 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. Document in case notes. Have access to written information on CDI (or relatives) including prevention and control measures. HPS. Version 3.0. March 2014 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 agreed locally specified) in Local Governance Reporting Procedure e.g. Risk Manager, Bed Manager, General Manager, Communication Representative and Health Protection Team, Medical Director, Director of Nursing. HPS 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. This may include non essential staff e.g. medical students 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. Version 3.0. March 2014 page 6 of 9
Day Clostridium difficile Infection (CDI) Trigger Tool Date: /./. (the date the trigger was identified) Daily CDI Trigger Checklist for completion by IPCT and Nurse until Trigger is resolved Date (dd/mm/yy) Completed by (initials) New symptomatic patients today New patients confirmed positive (microbiologically) Total symptomatic patients today Total positive patients today (include symptomatic) Increase or Decrease from yesterday Are any patients giving cause for concern due to CDI Y/N Y/N Y/N Y/N Y/N Y/N Y/N Patients placements: Isolation/cohort procedures are effectively established CDI patients have access to a dedicated commode / toilet and are supplied with dedicated care equipment. Patients placements: Doors to isolation/cohort areas (following risk assessment) are closed (clear signage). Patients placements: the segregation and care of patients with CDI in this clinical area is sufficient to prevent CDI cross-transmission. Discharge/Transfer Restrictions: Inter-care facility transfers are preagreed with IPCT. Intra-hospital transfers are only made if clinically necessary and the receiving area is prepared. Patient care checks: Clinical assessments are completed, recorded and action taken for today on all symptomatic and or positive patients. Patient care checks: Antibiotic prescribing for all patients has been reviewed today for compliance with policy. HCW practices & restrictions: Sufficient staff are on duty - all areas and all staff are asymptomatic. HCW practices & restrictions: Staff are allocated to care for patients in either isolation or non-isolation areas. HH and PPE (disposable gloves and apron): Soap and water is used for Hand Hygiene (HH). HH is done before donning PPE; PPE before entry to area; PPE removed before exit; HH after PPE removed. Safe Patient Environment (SPE): All areas are clutter free. SPE: Cleaning of isolation areas is established with detergent followed by or containing 1000 ppm av cl. SPE: X2 daily decontamination of frequently touched sites is done with detergent followed by or containing 1000 ppm av cl. SPE: There are sufficient supplies of PPE and essential sundries. SPE: Discontinuation of isolation is done after patients are symptom free for 48 hrs and their normal bowel function has been resumed. SPE: Following patient discharge, terminal cleaning is done preresuming normal services. Equipment: All ward equipment is visibly clean and in a ready-fornext-patient use condition. Equipment: There is sufficient dedicated equipment available in isolation/cohort areas - use of fans is avoided. Equipment: All commodes, including those in the isolation/cohort facilities, are clean and decontaminated with detergent followed by or containing 1000 ppm av cl after each usage. Knowledge Management: HCWs know how to practice safely. Knowledge Management: Patients/relatives/ know the situation and what precautions to take (includes patients being discharged). Knowledge Management: For discharged patients, GPs are being informed of any additional ongoing monitoring needed and, any actions should symptoms develop post discharge. IPCT to advise on ward status (open/closed) and patients placement HIIAT assessment today: Red / Amber / Green IPCT to advise if daily actions checklist still required If daily actions checklist no longer required - book terminal clean IPCT to confirm if re-opening criteria have been met Communicate all changes to email group HPS. Version 3.0. March 2014 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 that could have contributed to patient susceptibility? If yes, list the systems changed to rectify 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. Version 3.0. March 2014 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. Version 3.0. March 2014 page 9 of 9