CP064 -Clostridium Difficile Policy v3 - North Hampshire … · · 2013-06-21Clostridium...

Authorities Document Control Information

Author: Karen Davis-Blues Infection Control Nurse

Type: Policy

Sponsor: Paula ShobbrookDirector of Infection Prevention and Control

Scope: Major

Reference: CP064Issue Number: 3

Date January 2010 Status: Published

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Clostridium difficile Policy



Type: Policy

Scope: MajorSponsor: Paula ShobbrookDirector of Infection Prevention and Control

Trust Reference Number:

CP064

Reviewer(s): Members of the Infection Control CommitteeNursing Policy Group

Issue Number: 3

Approval body: Infection Control Committee reporting to Policy Approval Group

Status: Published

Effective Date: February 2010Review Date: February 2013Disposal Date: February 2035

Document Authorisation ControlPrepared By:Karen Davis-Blues Infection Control Nurse

Authorised OfficerMartin WakeleyChief Executive

Signature: Signature:

Winchester & Eastleigh Healthcare NHS TrustClostridium difficile



Type: Policy


Scope: Major



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DOCUMENT CONTROL

Document AmendmentsNumber Details By Whom Date1.0 Original document Mrs

T.Lewis Infection Control Nurse

June 2007

2 Amended to match Trust policy for the management of controlled documents and NHSLA Standard

Mrs S.Dailly Infection Control Nurse

January 2008

3.0 Amended to match new Dept of Health guidance Clostridium difficile infection : how to deal with the problem 2009

Ms. K. Davis-Blues Infection Control Nurse

January 2010

Review TimetableDate Reason By Whom Date CompletedJanuary 2013

Three year review cycle for policy document unless national guidance requires changes to be made sooner

Infection Control Nurse

Distribution ListNo Title1 Medical Director2 Nursing Director3 Divisional Clinical Directors4 All Wards and Departments5 Infection Control Committee Members




Type: Policy


Scope: Major



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6 WEHCT Intranet7 WEHCT Website8 Holders of IC manual

RELATED TRUST POLICIES

CP022 Isolation Policy CP021 Surveillance PolicyCP030 Overarching Decontamination policyCP077 Policy for ward closureCP076 Standard precautions and Personal Protective Equipment Policy CP064 Deceased infected patientOP001 Policy for the Management of Controlled DocumentsCP073 Hand hygiene PolicyCP061 Policy for Inter-ward Transfer of Patients with Infection Control IssuesPG011 Antibiotic policyCP008 Incident Management and reporting policy




Type: Policy


Scope: Major



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Contents

Section Title Page1.0 Purpose 62.0 Scope 63.0 Duties, roles and responsibilities 64.0 Introduction 85.0 Risk factors 106.0 Signs and symptoms 107.0 Specimens and diagnosis 118.0 Patient management and treatment 139.0 How is it spread? 1410.0 Protective clothing 1411.0 Handwashing 1412.0 Treatment of Clostridium difficile infections 1513.0 Ongoing assessment 1514.0 Clinical waste/linen 1615.0 Cutlery and crockery 1616.0 Medical equipment 1617.0 Movement of patients 1718.0 Cleaning and decontamination 1719.0 Equipment 1820.0 Following discharge 1821.0 Prevention and antibiotic prescribing 1922.0 Risk to healthcare staff and visitors 1923.0 Surveillance 2024.0 Death 2125.0 Training implications 2126.0 Monitoring compliance with and effectiveness of

the policy22

27.0 Definitions 2228.0 References 23

Appendix 1 Bristol stool chart 24Appendix 2 Twice daily cleaning of isolation room 25Appendix 3 Cleaning of a vacated isolation room 27Appendix 4 SIGHT poster 29Appendix 5 Medication that can produce diarrhoea 30Appendix 6 Care plan 31Appendix 7 Medical assessment algorithm 32Appendix 8 Period of Increased incidence(PII) 34




Type: Policy


Scope: Major



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Appendix 9 Equality impact assessment tool 35Appendix 10 Communication log 36

Winchester & Eastleigh Healthcare NHS TrustClostridium difficile Policy




Type: Policy

Scope: MajorReference: CP064

Date January 2010 Issue Number: 3 of 38 Status: Final

1 PURPOSE

This policy has been developed to provide a practical document to equip all healthcare staff at Winchester and Eastleigh Healthcare Trust (WEHCT) with the necessary information on the detection, management and prevention of Clostridium difficile. No single measure is sufficient to avert an outbreak of infection but adherence to this policy will help to achieve control of this preventable infection, maintain patient confidence and protect the hospital reputation.

2 SCOPE

This policy extends to cover all Winchester & Eastleigh Healthcare NHS Trust staff. This policy will also apply to honorary contract holders and staff employed by other organisations who work with the Winchester and Eastleigh Healthcare NHS Trust patients and for the Trusts’ other staff.

This policy complements professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC 2008).

Infection control is the responsibility of ALL staff associated with patient care. A high standard of infection control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care.

It is essential that infection control is seen as an organisational responsibility and priority, that adequate isolation facilities and resources are provided, and that appropriate infection control staff and support services are available.

This policy is ratified in line with the Trust’s Policy on Polices. (OP001 Policy for the Management of Controlled Documents)

3 DUTIES, ROLES AND RESPONSIBILITIES

3.1 Chief Executive Officer (CEO)The CEO has overall responsibility for ensuring the Trust has appropriate strategies, policies and procedures in place to ensure the Trust continues to work to best practice and complies with all legislation. The number of cases of C.difficile is reported monthly to the Board. Any clinical issues must also be discussed in a timely manner. The CEO has overall responsibility for the provision of adequate isolation facilities to enable national guidance on the control of Clostridium difficile to be implemented. There is a mandatory requirement for the CEO to report all cases of Clostridium difficile to the Health Protection Agency.

Winchester & Eastleigh Healthcare NHS Trust Clostridium difficile Policy

Authorities: Document Control Information:

Author: Karen Davis-Blues Type: Policy Sponsor: Director of Infection

Prevention and ControlScope: Major


Date January 2010 Status: publishedl

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3.2 Line managersLine Managers are responsible for ensuring this policy is accessible for all staff and that they have read and understood the content. Line managers are responsible for ensuring any changes in practice are implemented, and any further training needs identified and addressed. They should assist with the root cause analysis which will be carried out when patients have Clostridium difficile recorded on their death certificate or significant morbidity occurs or when deemed necessary.

3.3 Doctors Doctors should consider C. difficile infection (CDI) as a diagnosis in its own right, grading each confirmed case for severity (see appendix 7) treating accordingly and reviewing each patient daily regarding fluid resuscitation, electrolyte replacement, nutritional requirements, and monitoring bowel function using the Bristol stool chart. Monitor for signs of increasing severity of disease.

Clinical teams should review antibiotic prescribing on all their ward rounds, stopping unnecessary prescriptions and changing those that do not comply with guidelines.

3.4 Antimicrobial Management Team (AMT) and PharmacyThe Trust should ensure there are restrictive antibiotic guidelines that recommend narrow spectrum agents alone or in combination for empirical and definitive treatment where appropriate. These guidelines should avoid the use of second and third generation cephalosporins, in the adult population and in the over 65s, the use of fluoroquinolones, clindamycin and prolonged courses of co-amoxacillin.

Ward pharmacists will aim to carryout a daily review of drug charts to check appropriateness with the antibiotic guidelines and to liaise with the ward doctor. The 2009 Clostridium difficile infection: how to deal with the problem guidance, each Trust must have an antimicrobial management team (AMT) consisting of a pharmacist, a consultant microbiologist and information technology specialist. Trusts should ensure that there is prudent use of antibiotics and develop programmes to capture and feedback data to directorates and wards on antibiotic use and CDI rates. The AMT should carryout ward rounds and feedback to ward doctors and consultants.

3.5 All staffAll staff must ensure that their practice follows the current policies. Information regarding the failure to comply with the policy (e.g. lack of training, inadequate







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equipment) must be reported to the line manager and the incident reporting system used where appropriate.

The policy has a number of appendices that summarise the policy and are to be used by staff to care for their patients.

3.6 Infection Control Team (ICT)The Infection Control Team has a mandatory responsibility to report cases of Clostridium difficile to the Health Protection Agency via the national reporting system, the Strategic Health Authority and within the Trust. The ICT team offer advice to healthcare staff on treatment and isolation requirements. ICT members will collate data and disseminate within the Trust via the Infection Control Committee, the Infection Control divisional leads and the Trust Board.

3.7 Multidisciplinary review teamThe latest guidance recommends that the Trust establish a multidisciplinary review team consisting of a consultant microbiologist, infection control doctor, gastroenterologist or surgeon, a dietician and an Infection Control Nurse. The team should review all CDI patients at least weekly to ensure that the infection is optimally treated and the patient is receiving all necessary supportive care.

4.0 INTRODUCTION

4.1 WHAT IS CLOSTRIDIUM DIFFICILE?

Clostridium difficile is a spore forming gram-positive anaerobic bacterium which can cause infections of the gut. It can be found in the environment and in a minority of the healthy adult population (less than 5%) but probably higher in a hospitalised or institutionalised population. It is kept in check by the normal bacterial population of the intestine. Healthy adults carry at least 500 recognised bacterial species in their colon (mainly anaerobic). When this balance is disrupted organisms such as Clostridium difficile are able to multiply and produce toxins in the absence of competition. It is also common in the intestine of babies and infants but does not cause disease because the toxins do not damage their immature intestinal cells.

Clostridium difficile (C difficile), is a major cause of antibiotic associated diarrhoea and colitis (CDAD). The elderly (over 65 years), and the immunocompromised are more at risk from the infection. The bacterium produces toxins which damage the gut and cause diarrhoea of varying severity. In severe cases it can lead to death.

The spores produced by C difficile are resistant to drying, heat and many disinfectants and may survive in the environment for long periods which means the disease can be transmitted via the hands of healthcare workers or







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inanimate objects e.g. commodes. National guidelines recommend that hands are washed with soap and water after every patient contact. Alcohol hand rubs are not effective against the spores produced following C difficile infection and soap and water removes them more efficiently. See CP073 Hand hygiene policy.

C difficile imposes a significant financial burden on healthcare services. Each case costs the Trust on average £4000 and increases a patients’ length of stay by 21 days.

Case and outbreak definitions

When identifying and managing incidents of C difficile infection (CDI) the following definitions are recommended: C difficile associated diarrhoea is a diagnosis in its own right. C difficile infection : one episode of diarrhoea, defined either as stool loose

enough to take to take the shape of the container used to sample or as Bristol Stool chart types 5-7, that is not attributed to any other cause, including medicines (appendix 5) and that occurs at the same time as a positive toxin assay (with or without a positive C difficile culture) and /or endoscopic evidence of Pseudomembraneous colitis.(PMC)

A period of increased incidence (PII) of CDI: two or more new cases (occurring >48hrs post admission, not relapses) in a 28- day period on a ward. (See Appendix 8)

An outbreak of C difficile infection: two or more cases caused by the same strain related in time and place over a defined period that is based on date of onset of the first case.

An outbreak of Clostridium difficile If an outbreak is identified all the actions for PII (see appendix 8) will be carried out. In addition the bay or ward maybe closed to new admissions. The Trust will follow the guidance laid down in CP077 Policy for Ward Closure.

Any outbreak must be reported to the Primary Care Trust and the Strategic Health Authority as a serious untoward incident (SUI). A full root cause analysis will be carried out by the outbreak team to identify the causes and prevent further cases.

4.2 WHAT DOES THE TYPING SYSTEM MEAN?

The typing system analyses part of the C difficile DNA in a test called ribotyping. Over 100 types have been identified. Type 027 is increasing in the UK; the first isolate was identified in 1999 and the second in 2002. When outbreaks of C difficile were investigated, Type 027 was found to predominate in these cases. Type 027 produces more toxins when compared to other







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types, because a mutation has knocked out the gene that normally restricts toxin production. It causes a greater proportion of severe disease and appears to have a higher mortality. It also seems very capable of spreading between patients.

Other types, such as 106 and 01 are also common in the UK.

5.0 RISK FACTORS

There are certain groups of people who are particularly at risk of developing an infection caused by C difficile. These are listed below:

Older people > 65 yearsRecent course of antibiotics* (within the last 4 weeks)

Those who have recently undergone surgery Those with serious underlying disease Non surgical gastrointestinal procedures Presence of a nasogastric tube Stay on intensive care Duration of hospital stay Administration of multiple antibiotics or multiple courses Anti-ulcer medications

* Certain broad spectrum antibiotics (particularly the third generation cephalosporins but also quinolones and some other broad spectrum agents including betalactams) are harmful to the bacteria normally found in the gut, which can increase the risk of infection of C difficile. Recurrence of infection caused by C difficile can occur, which can be due to a relapse or a new infection in the same person, or the use of inappropriate antibiotic treatment of the initial infection.

6.0 SIGNS AND SYMPTOMS

C difficile can cause no symptoms but the most common is diarrhoea, ranging from a mild disturbance to a very severe illness with ulceration and bleeding from the colon (colitis), and at worst, perforation of the intestine leading to peritonitis and possibly death. Generally it is only able to do this when the normal, healthy intestinal bacterial have been killed off by antibiotics. When not held back by the normal bacteria, it multiplies in the intestine and produces two toxins (A and B) that damage the cells lining the intestine. The result is diarrhoea.







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Symptoms include:

Profuse watery diarrhoea Foul smelling diarrhoea – can have a green appearance Mucus and blood may also be present in the stool Abdominal pain / tenderness Fever Loss of appetite Nausea

POSSIBLE COMPLICATIONS

Relapse/re infection of diarrhoea – relapse/re infection can occur in 20-30% of patients

Pseudomembranous colitis Toxic megacolon – these patients may not present with diarrhoea as

they may have an ileus Perforations of the colon Sepsis Death

7.0 SPECIMENS AND DIAGNOSIS

7.1 TOXIN TESTING

C difficile infection should always be considered in any patient who develops unexplained diarrhoea and who is taking antibiotics or who has recently completed a course of antibiotics in the past few weeks. Infection with C difficile is routinely diagnosed by detection of the toxins A and B in faeces.

The SIGHT protocol and definition (see appendix 4) ensure that stool specimens are sent for toxin testing as soon as infective diarrhoea is suspected. All liquid stool samples in people aged > 2yrs are tested for C.difficile, within WEHCT.

In order to confirm a diagnosis it is therefore essential that diarrhoeal samples are sent as soon as possible for microbiological analysis. The specimen must be liquid and take the shape of the container in which it is placed. The sample does not have to be a ‘clean’ sample i.e. it can be contaminated with urine. This is the main diagnostic test and gives a result within a few hours of receipt of the sample. Please do not delay taking the sample and arranging transport to the laboratory since a result within 18 hours of the onset of symptoms is recommended. Testing is carried out routinely six days a week







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in the morning, but if clinical suspicion arises on a Sunday, the Consultant Microbiologist should be contacted to expedite testing on that day.

If the sample is not processed that morning, and the result is clinically necessary please contact the ICNs or the microbiologists to arrange to have the test carried out in the afternoon.

The ICN will phone the ward staff with all positive results during the week and will provide advice. At weekends the microbiology staff will phone any positive results to the ward staff and if clinical advice is needed, the Consultant Microbiologist on call should be contacted.

If symptoms resolve no further C difficile toxin test is required.

If symptoms persist despite treatment a further test for C difficile can be justified after 28 days from the previous positive result.

If symptoms resolve and then recur repeat C difficile testing can be done to confirm recurrent CDI, outside of the 28 days rule.

More than one test per patient may be required if the first test is negative but where there is a strong clinical indication for CDI. Retest 24hrs later and further testing may be required in light of clinical evidence, ICN/microbiologist will advise. This is due to the toxin not always being present in initial stool sample and can take up to 14 days, for the toxin to be in a large enough quantity to be detected.

7.2 CULTURE

The bacteria can also be grown (cultured) in a laboratory from a faecal sample. This is necessary for surveillance purposes or following outbreaks of infection. The isolates cultured can be sent to the Anaerobe Reference Laboratory for typing to identify specific strains linked to the outbreak. A particular strain of C difficile is known as type 027. This type may produce more toxins and has been reported to be associated with increased rates of mortality and relapses.

A small sample of the toxin positive stool is frozen and kept for 2 years, within the microbiology laboratory, so that a retrospective culture can be made if an outbreak situation occurs.







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8. 0 PATIENT MANAGEMENT AND TREATMENT

8.1 ISOLATION

Patients with diarrhoea, especially if severe or accompanied by incontinence, may unintentionally spread the infection to other patients. In addition, the ability of this bacterium to form spores (which other causes of diarrhoea, such as salmonella cannot do), enables it to survive for long periods in the environment, e.g. on floors and around toilets.

Isolating any patient who presents with unexplained diarrhoea should always be considered best practice to prevent the spread of infection and any patient with diarrhoea should be isolated, if possible, pending the results of investigations.

Following confirmation of a positive diagnosis of C difficile the patient must be moved into a single room with ensuite facilities (if not isolated already) and onto Victoria Ward unless this would be clinically detrimental to the patient.

In these rare occurrences the patient must be isolated on own ward, with the door shut, as above. If an ensuite toilet is not available a commode may be used and should remain in the room with the patient. Bedpans will be disposed of into the macerator.

If more than one patient is confirmed as having C difficile and there is a lack of isolation facilities, cohorting of patients is acceptable.

8.2 Cohort bay of patients with C difficile

1. The site coordinator and the ICT will allocate patients to the C difficile bay in consultation with ward staff. This will be on Victoria ward.

2. Patients admitted to a C difficile bay must have had active symptoms of diarrhoea within the last 24 hours.

3. All patients should have a stool chart and care plan (see appendix 6) which is accurately maintained.

4. All staff entering the cohort bay should wear gloves, aprons and wash their hands with soap and water before leaving and use alcohol gel once outside the bay. See for further details CP073 Hand hygiene; CP076 Standard Precaution and Personal Protective Equipment Policy.

5. Housekeeping staff should be informed and clean the bay twice daily with a detergent and chlorine agent combined i.e. Actichlor plus® (see appendix 2 and 3 for details of twice daily and terminal cleans). See for further details CP021 Overarching Decontamination Policy.

6. Bioquell® hydrogen peroxide vapour system to be used on the side room bays where possible in the Trust.







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A clinical incident form must be completed if either isolation or cohorting is not possible on the day of identification. This is the responsibility of the nurse in charge of the ward.

9.0 HOW IS IT SPREAD?

C difficile is spread by the faecal-oral route. Spores in the faeces can contaminate:1) Patients’ skin and hands.2) Hands of health care workers.3) The environment e.g. floors, bed tables and frequently touched items4) Equipment in the area around the patient e.g. commodes.

10.0 PROTECTIVE CLOTHING

All staff should wear a disposable plastic apron and gloves for direct patient contact or contact with their immediate environment (e.g. domestic cleaning), and when handling body excretions. The Trust advises the wearing of yellow plastic aprons for infected patients. These must be available outside the patients’ room, and be worn before entering the room and removed before leaving. See for further details CP076 Standard precautions and Personal Protective Equipment Policy.

Staff should also wear gloves and aprons when cleaning patient equipment or their environment. Used gloves and aprons should be discarded into an orange / yellow clinical waste bag.

11.0 HAND WASHING

The most efficient control measure in preventing person-to-person spread of this infection is the thorough washing of hands by health care staff before and after patient contact. Hands must be washed with soap and water following contact with the patient and removal of gloves and aprons. Alcohol gel is ineffective against the spores and soap and water removes them much more efficiently.

All patients must be offered the opportunity of hand washing following toilet / commode use and before meals. Ideally patients should be offered soap and water to clean their hands. (See CP073 hand hygiene policy) However if this is not possible, a moist hand wipe can be used as a less effective alternative.







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12.0 TREATMENT OF CLOSTRIDIUM DIFFICILE INFECTIONS

Not all patients who test positive for C difficile require treatment. Patients, who are now asymptomatic, need not be treated. Medical staff should review the requirement for the antibiotic which may have been associated with causing the C difficile diarrhoea if it is still being prescribed.

Anti-peristaltic agents e.g. loperamide and anti-motility agents are contraindicated in symptomatic patients and should not be prescribed as they increase the risk of Pseudomembranous colitis as the toxins will remain in the bowel for longer and therefore have more time to cause necrosis.

If treatment is required one of the following should be used:

Mild to moderate CDIMetronidazole – 400mg – 500mg tds orally for 7-14 days (1st choice for newly diagnosed cases, and first mild relapses)

Severe CDIVancomycin – 125mg qds orally for 7-14 days (2nd choice except in the very ill, and for severe first relapses and second relapses after Metronidazole). In severe CDI cases not responding, high dosage oral vancomycin oral / NGT (up to 500mg qds) +/- intravenous metronidazole 500mg tds is recommended The addition of oral Rifampicin (300mg) bd or IV immunoglobulin (400mg/kg) may also be considered.

Life threatening CDIOral vancomycin up to 500mg qds for 10-14 days via NGT or via rectal installation plus IV metronidazole 500mg tds. Specialist surgical input maybe required, colectomy should be considered if caecal dilation is >10cm.

See appendix 7 for the medical algorithm and definitions for mild, moderate and severe cases. Also see PG011 Antibiotic Policy.

These agents must be given orally or via a nasogastric tube as the IV route is ineffective for vancomycin.

Probiotics may have a role in preventing relapse and these may be recommended on a case by case basis by the Consultant Microbiologist.

13.0 ONGOING ASSESSMENT

The patient with diarrhoea must be assessed daily and their bowel pattern accurately documented on a stool chart using the Bristol stool chart for







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guidance. The Bristol Stool chart (appendix 1), is the most commonly used method to record and identify both normal and altered stool patterns and this should be documented in the patient’s notes on a daily basis.

Patients with C difficile are only infectious whilst they remain symptomatic i.e. whilst they still have diarrhoea. The patient once they have been free from symptoms for 48 hours i.e. passing a formed stool and stopped antibiotic treatment is classed as resolved. A clearance specimen is not required. The patient remains in isolation for their stay but can be cohorted with other resolved patients. The patient can only be transferred from Victoria ward after consultation with the microbiologist.

There is a risk of relapse of symptoms/re-infection in about 20-30% of patients and further courses of treatment may be required. If this occurs the patient should be regarded as infectious and moved back into a single isolation room and the ICT informed. If the patient has had a positive C difficile result within the last 28 days you do not need to send a repeat sample. If you are clinically concerned about the patient please discuss with the Consultant Microbiologist and Gastroenterologist.

The ICN will visit all positive patients at least weekly to assess their condition. If the patients’ diarrhoea continues and the ICN has clinical concerns the patient will be referred to the Consultant Microbiologist for further assessment.

14.0 CLINICAL WASTE / LINEN

All clinical waste will be disposed of into an orange/ yellow clinical waste bag.All linen will be treated as infected and disposed into an alginate bag and then into a red bag.

15.0 CUTLERY AND CROCKERY

Patients will use normal ward / kitchen issue. These will be cleaned by the dishwasher on the ward or in the central kitchen.

16.0 MEDICAL EQUIPMENT

Ideally allocate dedicated equipment that can remain in the patients’ room. These will need to be disinfected on discharge or when removing from the room. Disinfection can be achieved by cleaning first with a disinfectant wipe (Clinell®), followed by a clean with Actichlor Plus®. As detailed in CP030 Overarching Decontamination policy.







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17.0 MOVEMENT OF PATIENT

Patients who are symptomatic / confirmed C difficile should not be transferred to other wards except Victoria ward for isolation unless their condition necessitates transfer e.g. to ITU. Patients can be cohorted together on another ward in exceptional circumstances but only on the advice of the ICT in discussion with the site coordinator team. Symptomatic patients should also not leave the ward for investigations or treatment unless this is unavoidable. If an investigation is necessary please consider the following:

1) Is the diarrhoea so frequent the patient cannot visit the investigating department?

2) Can it be postponed until the patient is asymptomatic?3) Can it be performed on the ward?

If unable to do any of these:

1) Liaise with the infection control team.2) Inform staff at the receiving department who will then take the relevant

precautions e.g. put patient last on the list and arrange cleaning afterwards

3) Return the patient promptly to the ward after the investigation is complete. As detailed in CP061 Policy for Internal Transfer of patients with Infection Control Issues.

Essential physiotherapy and occupational therapy may still be undertaken but if not undertaken will be recorded in patients therapy notes. Staff should ensure that all relevant members of the multidisciplinary team are kept informed about the patients’ condition.

The patient may be transferred to a nursing / residential home or other care area once they have remained asymptomatic for 48 hours and are passing a formed stool. The discharge letter should include that the patient has had C difficile and what to consider if the patient develops loose stools once transferred.

18.0 CLEANING AND DECONTAMINATION

The environment around patients with C difficile can be heavily contaminated with C difficile spores. Commodes, toilets, wheelchairs, floors, sinks, and linen have all been found to be heavily contaminated. These spores can also survive in dust on the wards for months and even years. This environmental contamination is a potential source of infection transmission to other patients.







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To help prevent the spread of infection, the cleaning in areas with C difficile patients should be enhanced (see appendix 2 & 3). The patients’ bed area / room must be cleaned twice daily, including underneath the bed. In addition daily damp dusting of the patients’ bedside table, locker and all equipment in use must be performed. As detailed in CP030 Overarching Decontamination Policy.

A chlorine based detergent (Actichlor Plus®) is used routinely to disinfect areas occupied by infected patients, following national recommendations. This is because detergent alone will not effectively kill the C difficile spores and may actually help them germinate and produce more organisms. A chlorine based agent can be used alone following a clean with detergent and water, or once as a combined agent of detergent and chlorine e.g. Actichlor plus®.

19.0 EQUIPMENT

Whenever possible a patient with suspected or confirmed C difficile should have designated equipment and in particular a designated commode if ensuite facilities cannot be made available. All patient care equipment needs to be decontaminated daily / when visibly soiled and also in between each patient. See appendix 2 & 3 for details of a daily clean, terminal clean and individual responsibility.

Nursing and medical equipment should be damp dusted daily with both detergent and chlorine.

Commodes or toilets dedicated to infected patients should be cleaned at least twice daily with a detergent and chlorine agent i.e. Actichlor Plus® and in between use with detergent and water or disinfectant wipes (Clinell®). If the commode is visible soiled or is needed for another patient it must be cleaned with both detergent and chlorine i.e. Actichlor Plus® Single-use items should be used where appropriate.

20.0 FOLLOWING DISCHARGE

Following discharge or transfer of the patient a thorough terminal clean of the room and the furniture is required prior to the next patient using the room. Curtains and bed linen need to be removed prior to the cleaning and treated as per infected laundry. All medical equipment should be cleaned with a detergent wipe (Clinell®) for small pieces of equipment or electrical equipment and detergent and chlorine i.e. Actichlor Plus® for larger pieces and then removed from the vacated room.







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The area must be cleaned with detergent and water followed by a clean with chlorine based agent or alternatively with a detergent and chlorine agent i.e. Actichlor Plus®. Particular attention must be paid to the bed frame and mattress, toilet or commode and frequently touched surfaces such as door handles. Once the room has been vacated and cleaned ideally the room should also be Bioquelled®. Following the cleaning process the room is ready to be used again. As detailed in CP030 Overarching Decontamination policy and appendix 3.

21.0 PREVENTION AND ANTIBIOTIC PRESCRIBING

Health care providers should be encouraged to promote practices known to reduce the incidence of C difficile infection. These fall into two broad categories, the first being cleanliness and hygiene (including environmental cleaning and hand washing with soap and water -see above), and the second being a restrictive approach to antibiotic prescribing. The interventions when used together can have a major influence on the impact of C difficile.

A major risk factor for the development of C difficile is prior exposure to antibiotics, with cephalosporins and quinolones being particularly implicated. Those prescribing antibiotics should adhere to the Trust PG011 Antibiotic policy and guidelines (available from the Trust Intranet site) revised in 2009 and reviewed annually. There should be a daily review of the need for continuation of antibiotics in patients’ prescribed and receiving antibiotic therapy. When possible keep courses of antibiotics short and preferably use narrow-spectrum antibiotics rather than broad-spectrum drugs. Both of these actions will help to minimize the alteration of the normal bacterial flora of the bowel which is a key factor in the development of this condition. However even single dose antibiotic use has been implicated in some cases.

Following confirmation of a positive result the patients antibiotic regime needs to be reviewed and antibiotics discontinued if their clinical condition allows. The pharmacist or clinical microbiologist is available if advice is needed.

22.0 RISK TO HEALTH CARE STAFF AND VISITORS Most patients with this condition will have recently received / be still receiving a course of antibiotics. Healthcare staff and patients relatives are therefore at little risk of acquiring the infection themselves. However if these people are receiving a course of antibiotics themselves their risk of developing an infection will increase.

Explanation to the patients and their relatives is essential. If visitors are currently taking a course of antibiotics it might be advisable for them to







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rearrange their visit as they may be at a higher risk than others. However this will be dependent upon the patients’ condition so an assessment will need to be made on an individual basis.

Whilst the patient is symptomatic, all visitors / relatives who enter the room must wear a yellow apron and gloves, remove them whilst in the room and wash their hands with soap and water on leaving the room.

If staff are currently taking a course of antibiotics it is advisable that they do not care for that patient whilst they are symptomatic, unless there is a clinical need for them to do so.

It is important to maintain the patient’s privacy, dignity and confidentiality at all times.

23.0 SURVEILLANCE

Since January 2004 C difficile has been part of the Department of Health mandatory surveillance programme for healthcare associated infections. This programme requires all NHS Trusts to report to the Health Protection Agency (HPA), the number of cases of infections caused by C difficile diagnosed in patients 2 years of age and over in their Trust laboratory, whether the sample was sent from within the trust or elsewhere. Positive results on the same patient within 28 days are regarded as a single episode. A positive result on the same patient more than 28 days apart is reported as a separate episode. Trusts are ranked by the DH on an annual basis according to their CDT results. From April 2007 monthly reduction targets have been set as nationally the figures have been rising. The Trust and SHA monitor these figures weekly.

In addition to the mandatory surveillance programme this Trust also monitors the number of infections caused by C difficile diagnosed in patients of all ages > 2 years within the Trust. These numbers are recorded and reported back at the Infection Control Committee on a quarterly basis although are acted on contemporaneously. This surveillance helps to identify trends and highlight problem areas.

The Infection Control Nurses undertake enhanced surveillance on each positive patient. This involves collecting information from the patient on:

1) recent antibiotic history2) recent hospitalised admissions 3) reason for admission4) frequency and type of diarrhoea







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5) severity of infection, those requiring surgery, and those were CDI was the cause of death or contributed to it.

6) reviewing each patient at least weekly7) Referring patients with clinical severity or diarrhoea longer than 7 days

to a Consultant Microbiologist. Root cause analysis should be undertaken at clinical/divisional level on cases of serious morbidity and mortality.

24.0 DEATH

The Trust also collects local data on patients who die as a result of their C difficile infection. When C difficile is recorded as the main cause of death on a patients’ death certificate the ICNs will treat this as a clinical incident and generate a report via the Trust alerting system. A root cause analysis and action plan will then be undertaken and implemented at divisional level to ensure local learning informs best practice. If C. difficile is recorded as a secondary cause of death on the certificate then a Trust will be generated and an RCA maybe required.

25.0 TRAINING Implications

Infection control training on basic principles is part of the Trust wide mandatory training scheme for all staff and is monitored via attendance records.

Training is offered to all staff at induction

Training is offered to all staff at annual update

Antibiotic and infection control audits and updates are made quarterly to the Infection Control Committee and sent to every clinical team and ward

Specialty based training is offered via divisional meetings on an ongoing basis.

The link practitioners participate in a specialist programme of on going training.

It is the responsibility of individuals and their line managers to ensure attendance at training. The Training Department feedback non attendance to line managers and it is their responsibility to follow up non attenders and ensure their subsequent attendance.







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E learning for infection control is an acceptable alternative on alternate years once face to face induction is completed. E learning is accompanied by certification which can be used in evidence at appraisal.

26.0 MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY

There is a regular programme of audits, led by the Director of Infection and prevention and control (DIPC) and co-ordinated by the Infection Control Team, which are reported to the Infection Control Committee e.g. Hand Hygiene, use of Isolation facilities, infection control policy compliance, High Impact Interventions.

Divisional audits are reported via the divisions to the Infection Control committee and Patient Safety Committee.

Clostridium difficile surveillance and trends are reported to the Infection Control Committee (ICC)

Mandatory Clostridium difficile surveillance is reported to the ICC, divisions and Trust Board.

Serious Untoward Incidents (Infection) are discussed at ICC and reported to the Risk management and Governance Committee, Health Protection Agency and Strategic Health Authority

Antibiotic usage is monitored and audited by the Antibiotic Pharmacist and reported to the ICC and Drugs and Therapeutics Committee

Monthly reports on infection control and surveillance are taken by the DIPC to the Trust Board.

Training and education attendance is monitored by the Education Centre and reported to individual managers and collectively to the Executive Management Team.

The tool used to audit C difficile is currently based on the Saving Lives High Impact Intervention No6: Reducing the risk of infection from and the presence of Clostridium difficile. The audit tool may change to reflect new recommendations from the Department of Health.

There are regular audits of the quality of cleanliness in clinical areas by the Housekeeping department, executives and Matrons. The results of







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these audits are fedback and discussed at the Infection Control Committee meetings.

27.0 DEFINITIONS

3rd generation cephalosporins - are a class of β-lactam antibiotics

Broad spectrum betalactams - (namely penicillin’s, cephalosporins, monobactams and carbapenems) are the most widely used antibiotics, accounting for 65-70% of those available

Cohort - a well-defined group of subjects or patients who have had a common experience or exposure e.g. have Clostridium Difficile and are cared for together in a bay.

Ileus - intestinal obstruction: blockage of the intestine (especially the ileum) that prevents the contents of the intestine from passing to the lower bowel

Isolation – nursing the patient in a single room with barrier nursing precautions (the wearing of gloves and apron/gown for hands on contact).

Megacolon - A condition in which the colon enlarges and dilates, which results in faeces accumulating in the colon.

Probiotics Live, naturally-occurring microorganisms that function internally to promote healthy digestion, boost the immune system, and contribute to general health and wellbeing.

Pseudomembranous colitis - Pseudomembranous colitis is a severe inflammation in areas of the colon (large intestine) in which the lining of the colon becomes raw and bleeds

Quinolones - The quinolones are a family of broad-spectrum antibiotics

28.0 REFERENCES

Clostridium difficile infection: How to deal with the problem. Department of Health December 2008

Epic 2: National Evidence-based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England. The Journal of Hospital Infection. V 65 supplement 1, Feb 2007.

Healthcare Commission: Management, surveillance and prevention of Clostridium difficile. Health Protection Agency. December 2005







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National Clostridium difficile Standards Group. Report to the Department of Health. The Journal of Hospital Infection. V 56 supplement 1, Feb 2004.

Saving Lives: a delivery programme to reduce Healthcare Associated Infections including MRSA. Department of Health. 2006.

The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC London May 2008

Appendix 1







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Appendix 2

DAILY CLEANING PROCEDURE FOR A SINGLE ISOLATION ROOM / BEDSPACE OF PATIENTS WHO ARE KNOWN C DIFFICILE POSITIVE.

To help prevent the spread of C difficile infection, the patients’ immediate environment needs to receive an enhanced cleaning regime on both a twice daily basis and following discharge.

Single isolation rooms / bed spaces where there are patients with infective diarrhoea must be cleaned twice daily using a detergent and chlorine agent combined i.e. Actichlor Plus®. The nurse in charge of the ward is responsible for ensuring housekeeping is notified.

These areas should ideally be cleaned last, after the other rooms, bays and general ward areas.

All cleaning equipment used in these rooms must be kept exclusively for use within these rooms.

PROCEDURE

a. Put on single use gloves and aprons before entering isolation room. Discuss with nursing staff whether additional PPE is required.

b. Make up the combined detergent and chlorine product i.e. Actichlor Plus® in dilution bottle supplied using COLD WATER. Warm water results in the production of toxic chlorine gas.

c. Empty made up solution into a bucket / bowl (you may need to make up more than 1 litre to clean the entire room). The dilution bottle must always be used when making the solution.

d. Collect all equipment needed together.

DILTUTION INSTRUCTIONS TABLET SIZE = 1.7G

General environmental cleaning and equipment(1,000ppm)

1 tablet + 1 litre of Cold Water

= Correct dilution







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e. Wherever possible, ensure good ventilation of the room by opening the window.

f. Damp dust all surfaces using a single use cloth and the chlorine and detergent combined i.e. Actichlor Plus® solution. Make sure all hand contact surfaces are cleaned and dried thoroughly e.g. door handles, taps and toilet handles.

NB: It is the responsibility of the ward nursing staff to damp dust daily any nursing/medical equipment with detergent and chlorine i.e. Actichlor Plus®. Commodes dedicated to patients should be cleaned with detergent and water after every use and daily or when visibly soiled with a chlorine agent e.g. Actichlor Plus®

g. Clear floors of debris using disposable dust control cloths. The disposable cloths should be removed and disposed of in an orange / yellow bag.

h. Mop the floor with a solution of detergent and chlorine combined agent i.e. Actichlor Plus®. When finished, remove the mop head and send to the Mop Room for laundering.

i. Renew domestic waste bags.j. Check soap and alcohol gel wall dispensersk. Wash hands with soap and water on leaving the cubicle and

then use alcohol gel. l. Dispose of the solution of detergent and chlorine combined

agent i.e. Actichlor Plus® in the sluice. Wash and dry the bucket. Store in the cleaning cupboard.

The solution should be freshly made for use for each room, and thrown away down the sluice after each cleaning session. Not to be stored on the housekeeping trolley or the tablets.

A new solution should be made up every day.

The Actichlor Plus® solution should be changed when it becomes visibly dirty.

Chlorine based products e.g. Actichlor Plus® will bleach fabrics.

NB: Only personnel trained in the use of Combined chlorine and detergent i.e. Actichlor plus® should use this product.







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Appendix 3

CLEANING PROCEDURE FOR A VACATED SOURCE ISOLATION ROOM OR BEDSPACE FOR INFECTED DIARRHOEA EG CLOSTRIDIUM

DIFFICILE

The isolation rooms / bed spaces of patients who have infective diarrhoea must be thoroughly cleaned with both a detergent and chlorine agent, Actichlor Plus®. (Detergent alone will not effectively remove the C difficile spores).

The cleaning of the source isolation room / bed space is the responsibility of both the Housekeeping services and ward staff.

The nurse in charge of the ward is responsible for ensuring that a terminal clean using a chlorine agent is requested when patients are discharged from isolation rooms or transferred from bed spaces.

Ward staff responsibility

1. The patient must have vacated the bed space or room before cleaning commences.

2. All items of medical equipment should be surface cleaned with both detergent and a chlorine agent, such as Actichlor Plus® (safety permitting), and then should be removed from the vacated area.

3. All disposable fittings and medical devices should be disposed of as clinical waste e.g. oxygen tubing and suction tubing.

4. The room or area should be cleared of miscellaneous items.5. Following discharge of the patient, the bed mattress should be cleaned

with detergent and chlorine e.g. Actichlor Plus®.

For bed spaces in a four or six bedded bay a risk assessment of the other patients in the bay should be made regarding the risks of exposure to a chlorine based agent.

Housekeeping responsibility

1. Put on single use gloves and aprons before entering isolation room.2. Remove curtains and send to laundry. Wash and dry all hooks in

detergent and chlorine solution i.e. Actichlor plus®.3. Remove clinical and domestic waste. 4. Ensure room / area is well ventilated e.g. open windows.







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5. Remove any gross soiling from horizontal surfaces with detergent and water using disposable clothes.

6. Follow the procedure as per a daily clean ensuring all surfaces are cleaned with both detergent and chlorine e.g. Actichlor Plus®. Apart from medical equipment and the bed mattress the housekeeping staff is responsible for cleaning all other surfaces.

7. Remove the first twelve or so hand towels from the dispenser and discard toilet rolls. Replace with a new supply.

8. Walls should be washed using a non-malin velmop.9. Wash all internal windows with detergent and chlorine solution i.e.

Actichlor plus® and dry off with a paper towel. 10.All equipment, i.e. buckets, mop handles should be removed,

thoroughly cleaned using the detergent and chlorine solution i.e. Actichlor plus®, dried and stored in the cleaning cupboard.

The detergent and chlorine solution i.e. Actichlor Plus® should be changed when it becomes visibly dirty.When cleaning is completed, dispose of the detergent and chlorine solution i.e. Actichlor Plus® in the sluice. Replace clinical and domestic waste bin liners and check soap and alcohol wall dispensers.

The room is now ready for use.





Type: Policy



Appendix 4

Sight poster

SIG

T

H

Managing Suspected Potentially Infectious Diarrhoea

SUSPECT that a case may be infective where there is no clear alternative for diarrhoea.

ISOLATE the patient and consult with Infection Control Team

while determining the cause of the diarrhoea.

GLOVES & APRON for ALL contacts with the patient and their environment.



HAND WASHING with soap and water carried out before and after each contact with the patient and the patient’s environment.

TEST the stool for toxin . Send a specimen immediately.

Infection Control Team:Sue Dailly Ext. 4483 Bleep 177 Leslie Hollister Ext. 5156Karen Davis-Blues Ext. 5170 Bleep Sheryl Lucero Ext. 4383

Infection Control Team:Sue Dailly Ext. 4483 Bleep 177 Leslie Hollister Ext. 5156Karen Davis-Blues Ext. 5170 Bleep Sheryl Lucero Ext. 4383

Infection Control Team: Sue Dailly Ext. 4483 Bleep 177 Lesley Hollister Ext. 5156Karen Davis-Blues Ext. 5170 Bleep 192 Sheryl Lucero Ext. 4383







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Appendix 5Medicines that can produce diarrhoea

Diarrhoea is a common adverse drug reaction with many medicines Antimicrobials account for about 25% of drug-induced diarrhoea Many preparations contain sorbitol, caffeine and magnesium salts which can cause diarrhoea

If a patient has diarrhoea, especially due to Clostridium difficile, check if your patient is on any of the following medicines. If so, consider very carefully whether any can be stopped temporarily paying particular attention to the temporal relationship between the times that the medicine is first taken and when the diarrhoea first appears

Aminosalicylates particularly Olsalazine Antidiabetic agents particularly Acarbose and Metformin Antimicrobials - antibiotics, antifungals, antivirals, antimalarials, Bile salts – e.g. chlolestyramine Calcium preparations Cardiac glycosides Colchicine Cytotoxics Dipyridamole Gold preparations H2-receptor antagonists Immunosuppressants particularly Leflunomide and Azathioprine Iron preparations Laxatives Magnesium salts – e.g. antacids Metoclopramide Misoprostol NSAIDs – e.g. aspirin, ibuprofen Orlistat Proton Pump inhibitors – e.g. lansoprazole, omeprazole SSRIs Tranexamic acid Vitamin E (high doses) Zinc Some medicines used in parkinsonism Some medicines used in dementia

This list is not exhaustive. If you suspect a drug could be causing diarrhoea or you require further information about a specific drug then please contact Medicines Information on Ex 4294 or email [email protected]

mailto:[email protected]









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Type: Policy



Appendix 6C-Diff care plan

GOAL ACTION DATE SIGNATURE

1. To confirm a diagnosis when a patient has diarrhoea.

Follow the SIGHT pneumonic. If C. diff is suspected in a patient with diarrhoea please collect a stool specimen. The sample must be liquid i.e. it must take the form of the pot. NB: The sample can be contaminated with urine. It does not have to be ‘clean’. If possible move any patient with unexplained diarrhoea into a single room with its own toilet or commode.

2. To prevent the spread of C. diff to other patients.

Isolate patient in a single room or cohort in a bay with other proven C diff positive patients.(Cohort bays commenced with bed manager and I/C support). Ensure patient has their own toilet or commode.Inform Housekeeping so that cleaning regime can be enhanced. Staff to maintain an accurate stool chart using the Bristol stool chart.Isolation can be discontinued once the patient has been passing a formed stool for over 48 hours. NB a clearing specimen is not required.

Isolation commenced: Isolation discontinued: ...........

3. To provide timely appropriate treatment following the advice of the infection control team.

If treatment is required ward staff to ask patients medical team to prescribe a course of Antibiotics following the Medical Protocol for the treatment of C Diff associated Diarrhoea. This will include daily evaluation of patients’ condition: risk of malnutrition and dehydration.If diarrhoea or abdominal pain continues for 7 days please refer to microbiologist for further review.

4. To ensure patient is kept informed about C. diff status.

Inform patient of their positive result and the reason why isolation is needed whilst symptomatic.Also that they will be transferred to Victoria Ward (clinical condition dependant).Provide patient with a C. diff information leaflet. Visitors need to wear gloves and aprons and encouraged to wash their hands with soap and water before leaving the patients room.

Upon completion care plan to be filed in patients medical notes

Care Plan for a patient with positive Clostridium difficile (C diff) result.

Date positive:







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Appendix 7 Medical Algorithm







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Type: Policy



Appendix 8Period of increased incidence (PII) If there is a period of increased incidence the following actions should be undertaken:1. Urgently inform clinical director, matron, ward manager, DIPC and directorate

manager. Microbiologist and ICN should be the ones aware of the increase in incidence.

2. Conduct a weekly C.difficile audit using the Saving Lives High Impact Intervention. The audit should be weekly until achieving a score of >90% in three consecutive weeks and there have been no further cases of >48 hours (hospital acquired) cases of CDI. Audits must be fedback to ward staff and matron.

3. Carryout a weekly antibiotic review in the ward – this is the responsibility of the antibiotic pharmacist and the AMT.

4. Clean the whole ward with chlorine cleaning agent Actichlor Plus® using a separate cloth for each bed space.

5. Send all samples off to the Clostridium difficile ribotyping network for England, for ribotyping of all samples occurring during the PII.

6. The Infection Control Team should carryout a review of each case of C.difficile each week.

7. An incident meeting should be held to determine the possible causes of the PII and what action is required to reduce the risk.





Type: Policy



Appendix 9 - Equality Impact Assessment Tool

To be completed and attached to any controlled document when submitted to the appropriate committee for consideration and approval.

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Clostridium difficile Policy

Race No

Ethnic origins (including gypsies and travellers)

No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

No

4. Is the impact of the policy/guidance likely to be negative?

No

5. If so can the impact be avoided? No

6. What alternatives are there to achieving the policy/guidance without the impact?

No

7. Can we reduce the impact by taking different action?

No

If you have identified a potential discriminatory impact of this procedural document, please refer it to the Head of Corporate Services, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact:Board SecretaryTel No: 01962 825903





Type: Policy



Appendix 10 – Communications Log

Ref Policy Date of Issue

To Whom Signed as read and Understood

OP999 An example 09/09/1999 A Member of Staff

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