CoG (04/17) Item 19 DATE 11 April 2017 REPORT FOR Council of Governors SUBJECT Item for Information TITLE C difficile Action Plan BACKGROUND DOCUMENT (IF ANY) EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN THAT THE COG NEED TO BE MADE AWARE OF) COUNCIL ACTION REQUIRED To note the report
TRUST Clostridium difficile Post Infection Review findings and action plan April 2016 March 2017 Section 1: Actions identified following DIPC PIR s Section 2: Actions identified through other channels e.g. HCAI forum Author: Maurice Madeo. February 2017 Page 1 of 18
TRUST Clostridium difficile PIR ACTION PLAN 2016/17: as at 02/06/16 Section 1 : Actions brought forward from C. difficile PIR findings Ward: 22 SGH 09/05/2016 01/06/2016 No lapses in care Ensure agency staff aware of CDI 1.1 policy and the need to isolate if sample obtained and document patient symptoms and actions appropriately. 1.2 Ensure bank / agency provide staff with access to appropriate trust policies in advance of shifts to ensure conformity to trust standards. 1.3 A number of commodes were found to be soiled on Matron ward rounds / spot checks. Ensure a consistent robust method of cleaning of commodes in place and these are monitored daily by ward manager / nurse in charge. Matron - TD 27/06/2016 Email / IPCC Already spoken to nurse but will documentation when next on shift. Helen Clark to process in Bank Office 8/6/16 Matron - TD 29/06/2016 IPCC/email Quality Matron - CG Helen Clark to process in Bank Office and provide update 8/6/16 06/06/2016 HCAI forum Spot checks in progress and resulting showing 100% compliance. Feedback QM findings at next HCAI forum. Page 2 of 18
Ward: C1H 2.1 Initial stool sample collected on Path Links - Dr 20/06/2016 WebV The laboratory query adjusted admission and was not tested Vicca by laboratory because not meeting definition. Review the 10/05/2016 reporting of non-tested stool samples to ensure wards 03/06/2016 notified earlier which may prompt repeat sampling where indicated. No lapses in care 2.2 2.3 No CCG representative at PIR meeting to discuss treatment and management plan whilst at Lincoln / Louth (long standing diarrhoea). Discuss with commissioners whether it is possible for a CCG representative to dial in or physically attend future PIR meetings for NELCCG. Consider whether the case can be part of a future mortality due to multiagency involvement Deputy Chief Nurse - Sue Peckitt Head of Quality - Jeremy Daws 27/06/2016 IPCC 6/6 - SP discussed with CCG will try and attend if possible 25/07/2016 IPCC 6/6 - JD contacted and will add to list Page 3 of 18
Delay in collecting a stool sample IPCT 25/07/2016 IPCC Completed by AKW Ward: C7 3.1 in a patient who was recently diagnosed with CDI as staff use type 7 as the trigger. Clinical staff will need to be competency trained 31/05/16 re sampling criteria. 27/06/16 No lapses in care Page 4 of 18
Ward: C1K 03/06/16 11/07/16 4.1 4.2 Delay in taking a stool sample until third diarrhoeal episode. Ward staff need to take sample if fits criteria type 6-7 and unusual / abnormal for patient. Lack of isolation facilities resulting in delay in isolation. Escalate lack of single rooms to IPCC Ward manager / Matron 29/07/16 Email / IPCC Discussed with ward managers at time of meeting and followed up with information poster. DDIPC 29/08/16 IPCC An IPC audit has identified there is <20% isolation capacity within acute medical / surgical units No lapses in care but number of coincidental findings Page 5 of 18
Ward: Amethyst 09/06/16 18/07/16 Lapses in care 5.1 5.2 5.3 Dual prescribing of antimicrobials when not indicated e.g. Flucloxacillin and Co-amoxiclav Failure to isolate within 4 hrs as per trust standard. Clinical site team / Matrons aware but no immediate facilities available. To ensure the admission SOP for Amethyst ward is fully implemented and monitored by clinical staff. Ward not had a full deep clean since March 2015 - standard is 6 monthly for acute high risk medical wards Medical Director Microbiologist Matron / site management Estates / facilities director 18/07/16 IPCC Discussed with relevant clinical team at time of PIR. 29/07/16 IPCC IPC emailed medical matrons / and ADN for this to be uploaded 01/08/16. 01/08/16 IPCC Completed Page 6 of 18
Ward: Ward 18 SGH 22/06/16 6.1 No actions identified 08/07/16 No Lapses in care detected Page 7 of 18
Ward: C5 06/07/16 22/07/16 No lapses in care 7.1 7.2 7.3 Need to expedite deep clean as possible environmental contamination due to number of cases seen recently A number of environmental infrastructure changes required to help improve visibility (single rooms), storage and shower trays. Need to escalate to estates. Delay in from vascular nurse which may have delayed appropriate management- need to explore if additional capacity required. Matron 01/08/16 Facilities Escalated to facilities emailed Michelle Smith 01/08/16 and will arrange for wc 08/08. Deep clean completed LR 15/08/16 Escalation completed by LR Jen Orton - acting surgical ADN 15/08/16 Come under the SLA of Hull. Ensure all staff are aware stool Ward manager 09/09/16 Ward visit Kevin Taylor states action completed Ward: C5 8.1 samples / request forms must be labelled appropriately and sample discussed with nurse in charge to assess appropriateness. Ward 08/08/2016 manager to feedback at team meetings / debriefs. 18/08/2016 No lapses in care 8.2 Ward requires a full deep clean as 2 previous cases of CDI on the ward. Single room and bay identified to facilitate process. Matron (KT) 26/08/16 IPCC Deep clean completed email confirmation by M Smith 26/08/16 Page 8 of 18
Ward: Ward C7 stroke DPOW 13/08/16 Hull Royal Infirmary 9.1 No actions identified as PIR not held due to transfer of patient to Hull. Patient was already in SR and history of IBS sampled whilst in-pt NLaG but semiformed stool hence not tested for CDI. Sample taken on admission @ HRI post transfer from C7. PIR not held as no case notes Page 9 of 18
Ward: ICU SGH 01/09/16 Hull Royal Infirmary 10.1 No actions identified as PIR not held due to transfer of patient to Hull. Patient transferred to HRI with sepsis renal failure. Cephalosporins initiated by renal physicians whilst pt at NLAG. Sample taken on admission @ HRI post transfer from ICU. IPCN identified no lapses in care antimicrobials under guidance of the renal physicians HRI PIR not held as no case notes Page 10 of 18
Ward: C5 03/09/16 16/09/16 YES lapses in care/practice - 3 cases same ribotype 11.1 11.2 Lack of storage space on C5 causing difficulty with cleaning and general good housekeeping. Estates and senior ward staff to measure to be implemented to resolve issue. There appears to be some confusion on the role and responsibility of HCA, HSA and ward based staff re cleaning. Ensure ward manager receives an up to date protocol denoting roles & responsibilities. Matron / Ward manager / Estates manager Hotel services manager - MS 30/09/16 IPCC 30/09/16 Email Ward managers re-issued with the poster denoting roles of HSa and HCA sent on behalf of chief nurse. Nov 2016 11.3 The ward was noted to have unacceptable level of dust post deep clean. A further deep clean of the ward to take place ASAP in a systematic manner and bay / room sign off by Matron / senior nurse. Hotel services manager / Matron 30/09/16 IPCC Deep clean completed confirmation by M Smith Page 11 of 18
Bowel chart not recorded in Matron 03/10/2016 Email from Matron Completed. Ward: Laurel 12 accordance with best practice - action completed resulting in some poor documentation. Feedback to ward staff importance of stool chart 07/09/2016 documentation. 22/09/16 Unavoidable no lapses Ward: B4/2 04/09/2016 04/11/16 Unavoidable no lapses 13 Delay in patient isolation and sampling on presentation of loose stools whilst on B2. Ensure ward staff aware patients need to be isolated within 4 hours Ward manager B2 28/11/16 ICC DB Matron will feedback and B2 following PIR meeting. Page 12 of 18
Discuss case at future medical Dr Sarwar 27/02/2017 Ward: C6 14.1 staff training event to raise profile of danger related to CDI and suspicion of 11/11/2016 Pseudomembranous colitis 20/01/2017 Unavoidable / no lapses 14.2 Explore the use of NGT in patients who are not able to take oral medication diagnosed with severe CDI so that vancomycin can be administered. Ensure assessment documented in medical / nursing notes. Dr Sarwar / Sister 20/01/2017 Discussed at PIR and senior staff agreed to take this forward Ward: C1K 14/11/2016 15 Feedback to GP rationale for Cefalexin as no urine sample received from primary care and patient history of repeat UTIs. (noted has some mild CKD). AK 09/01/2017 Email / IPCC 12/12/2016 No lapses in care / practice Page 13 of 18
Ward: wd18 25/11/2016 16 Need to establish if night sweats are related to line infection - take blood cultures when temperature spikes from peripheral / PICC line Sister Immediately Email Line changed - completed 19/12/2016 Unavoidable / no lapses Additional clinical s not Dr Woosman 13/12/2016 Verbal / IPCC Completed Ward: C1K 17.1 taken e.g. sputum, urine antigen to rule out atypical pneumonia. Urine antigen for legionella requested by Dr Woosman. To feedback to jnr 27/11/2016 Drs need for clinical samples. 12/12/2016 Unavoidable / no lapses 17.2 Deep clean undertaken as part of an outbreak (Norovirus, rotavirus). Cleaning executed in a condensed manner leaving routine cleans / terminal cleans were delayed. Need to consider additional plans to accommodate sporadic deep cleans following outbreak. M Smith 13/02/2017 IPCC/email Case submitted to IPCC for additional deep clean operatives Page 14 of 18
Discuss case at future medical Dr Sarwar 27/02/2017 Ward: C6 18.1 staff training event to raise profile of danger related to CDI and suspicion of 11/12/16 Pseudomembranous colitis 20/01/17 No lapses 18.2 Explore the use of NGT in patients who are not able to take oral medication diagnosed with severe CDI so that vancomycin can be administered. Ensure assessment documented in medical / nursing notes. Dr Sarwar / Sister 20/01/2017 Discussed at PIR and senior staff agreed to take this forward Ward: Amethyst 15/12/2016 19 Slight delay in submitting a stool sample although the colour may have confused staff. Ward sister to reinforce in team briefs to suspect CDI if sudden alteration in bowel frequency and consistency and need for a stool sample. Ward Sister D Tansley 13/02/2017 email 11/01/2017 Unavoidable / no lapses Page 15 of 18
Ward: B2 18/12/16 26/01/17 No lapses 20.1 Admission staff must consider patients with a recent hospital stay and antimicrobials to be at risk of C.difficile, therefore a stool sample must be taken as soon as possible on admission if symptomatic e.g. type 6-7. 20.2 Delay in isolating a patient with loose stools - follow trust policy. Sister / Matron to ensure staff are conversant with the isolation policy and where to seek guidance if required. 20.3 Medical and nursing staff to ensure adequate communication is shared when ing a patient. Matron to feedback findings at local governance forum 20.4 Consider the use of a bowel chart on all admissions over 65yrs to facilitate improve bowel records - discuss at local governance forum / ward meetings. 20.5 There is no evidence to demonstrate single room had a deep clean upon vacation of patient. Hotel services to process of flagging up rooms requiring a deep clean e.g. use of WebV and ensure room deep cleaned if not done so. Matron Sister Matron Sister 02/02/2017 Matron to feedback to ward sister and cascade to all staff. Matron / IPC team to monitor 02/02/2017 Jnr Drs / Matron 08/02/2017 Matron 08/02/2017 Michelle Smith - Hotel services 02/02/2017 Review conducted by Hotel services / facilities and evidence room cleaned on discharge. Page 16 of 18
Ward: 28/HOBS 04/01/17 09/02/17 21 When stool sample taken ensure submitted to laboratory as soon as possible. Update staff that the laboratory is open weekends and will process samples Charge Nurse 07/03/17 email No lapses Ward: Laurel 23/01/17 17/02/17 No lapse in care but organisational issues Ensure when patients are 22.1 moved to a buddy ward as a medical outlier the patient s age and mental condition are taken into consideration. Operational Matrons / Site team to develop a proforma that can be shared with staff. Delay in discharge resulted in patient developing a HAP and subsequently died. 22.2 Raise at Infection Prevention Committee the risk of mixing medical patients onto a ward that has implants (breast). Clinical site team / Operational Matron / Simon Buckley DDIPC 27/03/2017 IPCC 20/03/2017 IPCC Discussed at morbidity and mortality meeting by Dr Wood 22/02/17 to raise issue with patient movement and delay in discharge. Page 17 of 18
Mr Sasapu Ward: B3 23.1 Matron 06/02/17 23/02/17 Lapse in practice (antimicrobial) 23.2 Extended surgical prophylaxis antimicrobials administered which are not in line with trust policy. Feedback to prescriber and ensure aware of local guidance. Nursing staff and pharmacy teams to challenge surgical prophylaxis if greater than 3 doses. IPC team to undertake an audit on compliance with surgical prophylaxis administration to determine whether actions embedded into practice. IPC team 13/03/2017 Audit 27/02/2017 Email Pharmacy to audit compliance as part of regular s. Page 18 of 18