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Key Words: Diarrhoea, Vomiting, Norovirus,

Version: 7

Adopted by: Quality Assurance Committee

Date adopted: 18 June 2019

Main author: Amanda Hemsley

Infection Prevention and Control Team

Name of responsible committee:

Infection Prevention and Control Committee

Quality Assurance Committee

Date issued: October 2019

Review date: September 2021

Expiry date: February 2022

Target audience: ALL LPT Staff

Type of Policy: Clinical

Non Clinical

This policy describes the management and procedures for patients who have diarrhoea and/or vomiting that is suspected or confirmed

as infectious.

For the management of patients where an increased incident or outbreak of infection is considered please see the operational ward

management policy for the management of patients with an increased incident or outbreak.

The Management of patients with

diarrhoea and/or vomiting

suspected or confirmed as

infectious

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Contents Page

Version control and summary of changes 3

Definitions that apply to this policy 4 1.0 Purpose 6 2.0 Summary and key points 6 3.0 Introduction 6 4.0 Management of patients with diarrhoea and/or

Vomiting of a suspected or confirmed infectious nature 8 4.1 Initial individual patient management (Bacterial and Viral) 8 4.2 Patients with suspected/confirmed symptomatic Clostridium

Difficile 9 4.3 Patients with suspected/confirmed symptomatic viral diarrhoea

and/or vomiting 11 4.4 Movement of patients 12 4.5 Visiting arrangements 13 4.6 Visiting healthcare staff, volunteers and ad hoc workers 13 4.7 Discharge of patients 13 4.8 Transport of symptomatic patients 14 4.9 Infection Prevention and control precautions in a patient’s own home 14 4.10 Staff sickness due to diarrhoea and/or vomiting 15

5.0 CDI 15 6.0 Training 18 7.0. References and associated documents 18

Appendix 1: Source isolation precautions poster 19 Appendix 2: Flowchart for the management of patients with

diarrhoea and/or vomiting 20 Appendix 3: Clinical Management of Clostridium difficile infection

(CDI) in the community 21 Appendix 4: CDI checklist (published by PHE CDI ‘Lapse in care’ 27 Appendix 5: Paperwork to be completed for CDI RCA 31

Contribution list 36 Circulation to 37

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Version Control and Summary of Changes

Date Comment

1 December 2006 First copy

2 December 2009 Review. Amended in line with DH guidance

3 February 2011 Added roles and responsibilities, Staff titles updated to reflect management of change

3.1 Harmonised in line with LCRCHS, LPT and LCCHS (Historical organisations)

4 August 2014 Reviewed by the IPC team in line with latest guidance. Incorporated; ‘Guidance on undertaking faecal specimens; IPC precautions for patients in their own homes; role specific training for CQC outcomes 4/5/8 Checklist for immediate management of a patient with diarrhoea and/or vomiting. Flowchart for the management of patient with Cdifficile, diarrhoea and/or vomiting in community hospitals. Clinical management of C.difficile in the community including undertaking daily patient assessments, UHL microbiology contacts, Inter-Healthcare Transfer form

5 August 2015 Change of title policy to reflect content, Reviewed policy to ensure correct in in line with latest guidance.

6 March 2019 Review date Changes made to the document include separation of the management of a patient with potential viral causes for the symptoms and CDT management. Source isolation poster reworked Flowchart for the management of patients with symptoms reworked

7 October 2019 Reviewed in line with the NHSi document - Clostridium difficile infection objectives for NHS organisations in 2019/20 and guidance on the intention to review financial sanctions and sampling rates from 2020/21

For further information contact: Infection Prevention and Control Team

5 The management of patients with diarrhea and/or vomiting suspected or confirmed as infectious Version 7

Definitions that apply to this policy

Adenovirus Types 40 and 41 cause gastroenteritis especially in children under the age of two. The virus is transmitted by the faecal-oral route with an incubation period of 3-10 days, and lasts approximately one week. Diarrhoea is more prominent than vomiting or fever, and respiratory symptoms are often present. Long term immunity is acquired in childhood.

Asymptomatic Having no symptoms of illness or disease

Bristol Stool Chart (BSC)

The Bristol stool chart is a diagnostic medical tool used to classify the form of human faeces into seven categories.

Clostridium difficile Infection (CDI)

Clostridium difficile infection (CDI) id due to toxin-producing bacteria that causes a more severe form of antibiotic associated diarrhoea. The disease ranges from mild diarrhoea to severe colon inflammation that can be fatal.

Clostridioides difficile

Clostridioides difficile also known as Peptoclostridium difficile is Gram positive species of spore-forming bacteria

Diarrhoea Diarrhoea is the increased frequency of passing a loose stool that is either a stool loose enough to take the shape of a container used to sample it or noted on the Bristol Stool Chart (BSC) types 5-7 (appendix 2).

Increased incidence Where cases of the same infection linked in time or place are greater in number than is considered ‘normal’ or acceptable for that area.

Infection The invasion and multiplication of microorganisms such as bacteria, viruses and parasites that are not normally present within the body.

Infectious A disease or disease causing organism able to be passed from one person, animal or plant to another.

Isolate (isolation) When a patient is cared for in a separate area or room from others, due to them having an infection that may be detrimental to another patient/person’s health.

Norovirus Norovirus has a small infective dose with an incubation period of 12-48 hours. Peak viral shedding occurs between two to five days. The virus is transmitted by the faecal-oral route or from contaminated surroundings. Symptoms typically exist for one or two days and are usually mild in nature. However for elderly or individuals with pre-existing health conditions they may be more serious in nature, and continue for four to seven days.

Organism An individual animal, plant or single-celled life form

Outbreak A disease outbreak is the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season.

Personal Protective Equipment

Specialised clothing or equipment worn by employees for protection against health and safety hazards e.g. single use gloves, aprons, surgical gowns, masks and eye protection.

Rotavirus This is the most common cause of severe diarrhoea among infants and young children. Immunity develops with each

5 The management of patients with diarrhea and/or vomiting suspected or confirmed as infectious Version 7

infection, so subsequent infections are less severe; adults are rarely affected. Rotavirus gastroenteritis is characterised by vomiting and watery diarrhoea, ad low-grade fever. The incubation period is around two days. Symptoms often start with vomiting followed by four to eight days of profuse diarrhoea. Rotavirus vaccine is now routinely offered to infants.

Vomiting The act of ejecting the contents of the stomach through the mouth as a result of involuntary spasms of the stomach or oesophagus

Viral infection Caused by the presence of a virus in the body.

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1.0 Purpose of the policy The purpose of this policy is to inform all healthcare staff within Leicestershire Partnership Trust (LPT) of the management and actions required in the management of patient/s who experience diarrhoea and/or vomiting which is of a suspected or confirmed infectious nature. Prompt recognition of viral diarrhoea and vomiting will reduce the risk of transmission of infection by reducing the movement of the patient and contacts and therefore preventing cross infection or contamination within the healthcare environment. The policy for the management of increased incidents should also be consulted, when the cause is considered to be viral in nature.

2.0 Summary and key points

It is imperative that a patient’s normal bowel habit, type and frequency is identified and documented when the patient first comes under the care of LPT. Without this documented assessment it is not possible to determine if a patient is passing a stool that is not part of their normal bowel habit.

There can be non-infectious reasons for a patient to experience diarrhoea and/or vomiting which needs to be eliminated before an assumption is made that it is of an infectious nature.

It is reasonable to instigate source isolation precautions for a patient whilst this assessment is being undertaken if there is a considered risk of infection however faecal samples must only be sent if an infectious cause is being considered.

Infectious diarrhoea and vomiting may be due to a wide range of micro-organisms, but the ones most likely to be encountered in healthcare settings are viruses such as Norovirus, and bacteria such as those that cause food poisoning e.g. salmonella, campylobacter and bacteria that produce a toxin such as Clostridium difficile.

It is important that staff can recognise diarrhoea and vomiting that may be of an infectious nature and instigate procedures to reduce spread and transmission as promptly as possible.

3.0 Introduction

The emergence of Clostridium difficile as a clinically and politically significant health care associated infection from 2005 onwards, together with the increasing impact of Norovirus infection on the function of health care organisations, means that sensitivity to diarrhoea has developed with a resulting high suspicion of infectiousness when it occurs. The most common causes of infectious viral diarrhoea and/or vomiting are Noroviruses, followed by Adenoviruses and then Rotaviruses.

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Norovirus accounts for at least 50% of all viral gastroenteritis outbreaks worldwide and can be detected throughout the year. An estimated 600,000 to a million people contract Norovirus annually in the United Kingdom, mainly in their own homes. In England approximately 3000 people a year are admitted to hospital with Norovirus. The Hospital Norovirus Outbreak Reporting System (HNORS) in England estimate that, on average reported outbreaks are associated with 13,000 patients and 3,400 staff becoming ill, 8,900 days of ward closure and the loss of over 15500 bed-days annually with a cost to the NHS in excess of £100 million per annum in years of high incidence. Transmission of organisms, which cause diarrhoea and/or vomiting, is mainly by the faecal-oral route (unwashed hands after visiting the toilet and handling patient’s soiled clothing, bed linen etc.). Some organisms are spread by direct contact and by the airborne route, caused by widespread aerosol contamination during vomiting and by widespread environmental spread during bouts of diarrhoea. Food borne illness can occur directly through environmental contamination as above. Norovirus’s mode of transmission is contact via the faecal-oral route and airborne via inhalation followed by ingestion of norovirus-contaminated aerosolised vomit. Patients with projectile vomiting can disseminate large quantities of virus laden aerosols which can contaminate extensive areas of the environment. Cross-transmission can then occur when patients and staff inhale and subsequently ingest these virus laden aerosols, or consume food on which these aerosols have landed. NB 30mls of vomit may contain up to 30,000,000 virus particles (HPS 2009). Acquisition of Clostridium difficile occurs by the ingestion of viable bacteria or spores from the environment, including via cross-transmission from other carriers in the health care setting. Not all individuals who acquire C. difficile will develop symptoms; predisposing patient factors, including age, immune status and antibiotic use, may also impact on whether clinical disease will develop. Causes of diarrhoea

Royal College of Nursing 2013

NB: If a suspected or confirmed increased incident or outbreak of infection is being considered please refer to the policy for the ward management of an increased incidence or outbreak of infection policy for further information.

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4.0 Management of patients with diarrhoea and/or vomiting of a suspected or confirmed infectious nature

Please telephone the Infection Prevention and Control team for advice at the earliest opportunity.

4.1 Initial individual patient management (Viral and Bacterial) Any patient who is admitted to hospital/inpatient facility with or develops diarrhoea and/or vomiting and under the care of LPT staff must, as a priority, have the following assessed and documented:

Normal bowel function – frequency and type. This is what is normal for the patient when they are well, it may not necessarily be the bowel function they present with on admission to hospital.

Assess cause of diarrhoea and/or vomiting including underlying conditions (including previous history of CDT or underlying bowel disease), antibiotics, laxatives, proton pump inhibitors, nutrition/dietary fibre, history of recent travel, any recent anaesthetic or bowel surgery.

In assessing diarrhoea it is important to determine the duration, frequency, pattern, type (watery; bloody; fatty), odour and severity of symptoms.

If the onset of diarrhoea and/or vomiting is sudden and the symptoms are not clearly attributable to an underlying condition or therapy, the patient must be isolated. Do not wait for further episodes of diarrhoea and/or vomiting.

Once establishment of new onset acute diarrhoea has been established, application of the acronym “SIGHT” (DH 2009) must be instigated;

S Suspect that a case may be infective where there is no clear alternative cause for diarrhoea

I Isolate the patient while determining the cause of the diarrhoea

G Gloves and aprons must be used for all contacts with the patient and their environment

H Hand washing with soap and water should be carried out before and after each contact with the patient and their environment

T Test the stool for infection by sending a specimen immediately, send for virology and/or virology

NB: Faecal samples should only be taken if considering an infectious cause. 4.2 Patients with suspected/confirmed symptomatic Clostridium difficile

a) The following documentation must be completed and plans commenced; Review of the patient’s current medication by the doctor/ANP/Healthcare

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practitioner (to include):

Current antibiotic treatments

Laxatives

Proton pump inhibitors

b) Accurate fluid balance management must be instigated and documented including:

Fluid balance chart

Diarrhoea checklist

Bristol stool chart

Electrolyte replacement

Nutrition assessment and requirements

Management of CDT guidance

c) Obtaining specimens must include the consideration that the patient may have had a previous positive result for CDT:

Consider contacting the patients GP or referring hospital for further information as samples may be sent outside of LLR’s geographical area dependent on the patient’s home address.

Where there is no previous history of CDT and an infectious cause is being considered a faecal specimen should be collected and sent to the microbiology department requesting microscopy, culture and sensitivity (MC&S) and CDT.

Faecal samples taken on a weekend or bank holiday should be sent the same day, via taxi if necessary, and in an appropriate container. A delay in sending samples until the next working day could result in a delay in appropriate treatment.

A patient previously known to have CDT within the last 28 days does not require a further faecal sample to be tested, and must not be sent, but they should be treated as if they are positive for CDT. Treatment advice can be obtained from microbiology.

Clearance and repeat specimens for Clostridium difficile toxin are not necessary after initial diagnosis.

A patient with a positive sample for CDT must be managed using the CDT care pathway (Appendix 7) and the clinical management of CDI for adult patients/service users in the community (Appendix 6).

The CDI clinical management pathway that is used by the Trust refers to CDI as either non-severe CDI or severe CDI. A patient diagnosed with CDT, must have clear documentation in their notes whether the CDT is considered by the clinician in charge to be non-severe CDI or severe CDI. (The Department of Health defines CDI as either mild, moderate, severe or life threatening).

If systmone is used, a high priority reminder must be placed on the patient record if they are diagnosed with CDT.

If RIO is used, an alert reminder must be placed on the patient record RIO if the patient is diagnosed with CDT.

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Mild CDI Not associated with a raised WCC Typically associated with <3 stools of type 5 – 7 on the BSC per day.

Moderate CDI Associated with a raised WCC that is <15 x 109/L Typically associated with 3 – 5 stools on the BSC per day.

Severe CDI (one or more)

Associated with a WCC >15 x 109/L or Acute rising serum creatinine (i.e. >50% increase above baseline), or Temperature of >38.5°C or Evidence of severe colitis (abdominal or radiological signs). The number of stools may be less reliable indicator of severity.

Life-threatening CDI

Includes hypotension, partial or complete ileus or toxic megacolon, or CT evidence of severe disease.

Department of Health 2009

If a negative sample for CDT is obtained and the patient is still having diarrhoea and/or vomiting of an unknown cause it is important that other causes are considered and assessed for.

d) Patient Care and management regarding source isolation precautions

If a patient is having diarrhoea they should be moved into a single room wherever possible if not already nursed in one, and source isolation precautions commenced.

The patient must have an allocated toilet for their sole use; if this is not possible then a risk assessment must be carried out, identifying what processes have been put in place to minimise the risk of cross contamination to other patients.

A risk assessment must be carried out and clearly documented in the patients care plan where a single room is required but not available.

Source isolation precautions must be adhered to where a patient is nursed in a bay, with an allocated toilet.

A commode must not be used at the bedside (as other patients will be eating, drinking and sleeping in this area).

The infection prevention and control team must be informed of patients requiring source isolation precautions as soon as practicable by telephone. The source isolation form (see Appendix 1) must also be completed and displayed outside the patient’s single room or bed space.

Where possible the single room or bay should have a door and this should be kept shut.

If it is not possible for the door to be kept shut a written risk assessment must be completed and documented in the patients notes. This should identify the possible risk of cross infection.

The patient’s charts and notes must not be taken into the single room.

A patient must continue with source isolation precautions until they have been asymptomatic for at least 48 hours and have passed a formed stool or a normal stool for them or following discussion with the infection prevention and control team.

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4.3 Patient/s with suspected/confirmed Viral diarrhoea and/or vomiting

a) The following documentation must be completed and plans commenced; Review of the patient’s current medication by the doctor/ANP/Healthcare practitioner (to include):

Current antibiotic treatments

Laxatives

b) Accurate fluid balance management must be instigated and documented including:

Fluid balance chart

Diarrhoea checklist

Bristol stool chart

Electrolyte replacement

Nutrition assessment and requirements

c) Diagnosis of norovirus infection is often made on clinical grounds from their characteristic features. However the infection can be confirmed following testing of a stool sample.

Obtaining specimens must include a sample specifically for virology as this is not routinely tested.

Vomit must not be sent to microbiology. If sent it will be discarded and not tested.

Stool samples must be taken from every patient who has diarrhoea and thought to be infected; If the sample is contaminated with urine it can still be sent.

Faeces scraped off the sheet or incontinence pad can also be used if unable to obtain a sample from a bedpan/toilet.

The sample should contain the runniest part of the sample.

Faecal samples taken on a weekend or bank holiday should be sent the same day, where possible or the day after if stored appropriately overnight. A delay in sending samples may result in inaccurate results.

Never wait for positive results before implementing infection prevention and control precautions and outbreak control measures. Viral gastroenteritis is most infectious in the early stages.

d) Patient Care and management regarding source isolation precautions

If a patient is having diarrhoea they should remain in their bed space and source isolation precautions commenced immediately (irrespective of whether they are in a single room or a bay).

If the patient is nursed in a bay, source isolation precautions must be undertaken individually with all patients in that bay.

A toilet must be allocated for the sole use of the patients within the area where source isolation precautions are being undertaken and cleaned between use with chlorclean

A commode must not be used at the bedside (as other patients will be eating,

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drinking and sleeping in this area).

The infection prevention and control team must be informed of patients requiring source isolation precautions as soon as practicable by telephone. The source isolation form (see Appendix 1) must also be completed and displayed outside the patient’s single room or bed space.

Where possible the single room or bay should have a door and this should be kept shut.

If it is not possible for the door to be kept shut a written risk assessment must be completed and documented in the patients notes. This must identify the possible risk of cross infection.

The patient’s charts and notes must not be taken into the side room.

A patient must continue with source isolation precautions until they have been asymptomatic for at least 48 hours and have passed a formed stool or a normal stool for them or following discussion with the infection prevention and control team.

Only the affected bays need to be closed to admissions and the policy for increased incidents referred to.

4.4 Movement of patients

Symptomatic patients with diarrhoea and/or vomiting must not be transferred to other wards within LPT, except for purposes of isolation or on clinical need.

For all transfers the Essential Steps Inter-healthcare Transfer Form must be completed and accompany the patient (Appendix 9). This decision must be made in consultation with the infection prevention and control team or the on call manager and be based on a clinical assessment of the risk to other patients.

Visits to other departments must be kept to a minimum. When this is necessary, either for investigation or treatment, prior arrangements must be made with the manager of that department, so that the trust source isolation policy and the trust policy for cleaning and decontamination can be implemented.

Symptomatic patients should be seen immediately or at the end of the working session. They should only be sent for when the department is ready to see them; they should not be left in the waiting room/ area with other patients.

If visits to other hospitals are considered necessary the receiving area should be informed of the patient’s status in advance.

Where possible patients should be treated at the end of a session and their waiting time in the department kept to a minimum.

The patient must be transported via the ambulance service that must also be made aware of the patients’ status in advice.

The patient must not travel with other patients in the same vehicle.

A full terminal clean must be carried out for every bed area and equipment An increase in patient throughput and admission to the acute hospitals during the winter period may also put pressure on the availability of beds. In order to support the admission of patients into beds with the most clinical need, during periods of high levels of Norovirus/viral diarrhoea and/or vomiting patients may be discharged after 24 hours of being asymptomatic, but are clinically fit to be transferred. This 24 hour default position currently is not in line with national policy and must be done with consultation from the IPC team and in conjunction with the service lead/manager and

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lead nurse for LPT. 4.5 Visiting arrangements

Patients in source isolation may be visited by family and friends.

Visitors do not routinely need to wear protective garments

Advice must be provided by the nursing staff if relatives are involved with direct patient care. They should then wear disposable gloves and aprons, removing them after use and placing them into clinical waste, then wash their hands with soap and water and dry them, before decontaminating them with alcohol sanitiser.

Visitors must be advised not to visit if they are suffering from diarrhoea and vomiting and for 48 hours after their symptoms have ceased.

In some rare circumstances the ward may be completely closed to visitors. 4.6 Visiting health care staff, volunteers and ad hoc workers

Non-essential therapy may need to be delayed or suspended for symptomatic patients if they are unwell.

A risk assessment must be completed to ascertain the risk to other patients if therapy continues.

Volunteers must report to the nurse in charge for advice and guidelines on what duties they may undertake with regard to symptomatic patients. It is the responsibility of the nurse in charge to ensure the volunteer is aware of any precautions that need to be taken.

Visitors such as hairdressers, trolley vendors and similar non-essential visitors must not be allowed to restricted areas until the restrictions have been lifted and appropriate cleaning carried out.

4.7 Discharge of patients

Patients who are symptomatic with diarrhoea and/or vomiting may be considered for discharge to other hospitals, nursing and residential homes.

This must be discussed in advance with the receiving area/carers to ensure that adequate facilities (i.e. ability to provide source isolations precautions) and necessary equipment are available.

The receiving hospital, nursing or residential home must confirm appropriate arrangements are in place prior to admission. This must be documented in the patient’s notes and discharge documentation.

In the event that the place of discharge does not have the appropriate facilities to isolate the patient, the transfer then must be delayed until the patient has been symptom free for at least 48 hours.

Symptomatic patients with diarrhoea and/or vomiting can be considered for discharge to their own home if they are deemed to be medically fit and a package of care in place to ensure that the patient is managed safely. This must be discussed in advance with the Community Services and family if they are going to be involved in their care or living with them. This must be documented in the patient’s notes and discharge documentation.

It is the responsibility of the discharging Doctor/Advanced Nurse Practitioner to communicate with the General Practitioners (GP) about symptomatic patients

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who are being discharged into the care of the community. The GP should also be informed of those patients who have recovered from diarrhoea and/or vomiting but are no longer symptomatic on the discharge letter.

The infection prevention and control team must be informed of the final decision regarding the discharge of symptomatic patients.

4.8 Transport of symptomatic patients

A patient who is symptomatic and is to be discharged from a community hospital to another place of care or to their own home, transport arrangements must be planned in advance.

If planning in advance is not possible due to the patient requiring an emergency transfer then where possible the ambulance crew and receiving hospital must be informed of the patient’s symptoms and potential infection risk.

If the patient is to be transferred by ambulance, the ambulance liaison officer must be advised of the patient’s diagnosis and the need for a designated ambulance. The ambulance liaison officer will need to be informed of the source isolation precautions required.

Patients must not be transferred by taxi or volunteer cars.

A patient who is discharged and is using personal private transport must be provided with the appropriate equipment (i.e. disposable nitrile gloves, disposable aprons, disposable vomit bowls and continence pads) for the driver, who must be advised of the infection prevention and control precautions necessary in the event of a body fluid spillage.

The importance of hand decontamination following handling of body fluids and waste must be discussed as well as the importance of hand washing using soap and water at the earliest convenience. Any waste must be double bagged and disposed of as normal household waste.

4.9 Infection prevention and control precautions in a patient’s own home

When visiting patients who are suspected of or have a confirmed vomiting and/or diarrhoeal infection in their own home, a good standard of infection prevention and control precautions must be maintained to prevent carriage of transient organisms between patients.

All practices identified for caring for a patient in an inpatient area including; hand hygiene, use of personal protective equipment and cleaning of equipment (belonging to LPT) must be adhered to for patients in their own home.

Carers and/or relatives caring for someone with suspected vomiting and/or diarrhoea should be encouraged/advised:

That (if prescribed) the patient must complete a course of antibiotics even if they feel better

Encouraging the patient to drink fluids

To practice good hand hygiene (following removal of gloves and aprons) for example; after using the toilet / changing nappies, after handling rubbish and before and after preparing food and drinks

To keep all surfaces clean. (With a bleach-based household detergent if the

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surface will withstand it).

The importance of washing all bedding, towels and clothing on the hottest cycle the fabric(s) will allow

Foul linen should not come into contact with ordinary household laundry Carers and/or relatives caring for someone with positive stool sample/clinical symptoms for Clostridium difficile infection must be advised (in addition to the above) on:

Arrangements need to be in place (e.g. patient/family member, carer, district nurse) to carry out DAILY assessment to identify and report worsening symptoms and to alert the patient’s General Practitioner on:

Temperature – is it raised? Is the abdomen bloated?

Is there abdominal pain? Increased frequency and change of stool type (use Bristol Stool Chart and

record frequency and type)

Hydration and nutritional status If this advice is given to relatives it is imperative the staff giving the advice ascertain that the relative is able and happy to take on this responsibility, and this must be documented accordingly.

4.10 Staff sickness due to diarrhoea and/or vomiting

Occupational health must be informed of symptomatic staff. All staff must remain off work until they have been symptom free for 48 hours. Advice regarding symptomatic staff will be given by occupational health.

5.0 CDI

Trajectories for the financial year are calculated using data from 1 April - 31 December of the same year. Cases are attributed to a trust depending on when they are detected and where the patient was when the result was detected, or immediately prior to detection. For the purposes of LPT this equates to the following: Hospital onset healthcare associated cases are those that are detected in the hospital 2 or more days following admission Community onset healthcare associated cases are those that are detected in the community, or within 2 days of admission as an inpatient when the patient has been an inpatient within LPT in the previous 4 weeks. Community onset indeterminate associated cases are those that occur in the community, or within 2 days of admission as an inpatient where the patietnhas been an inpatient within LPT in the previous 12 weeks but not in the most recent 4 weeks Community onset, community associated cases are those that occur in the community, or within 2 days of admission as an inpatient where the patient has not been an inpatient within LPT in the previous 12 weeks.

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It is imperative that all patients that have loose stools (as defined on the Bristol Stool Chart as type 5 - 7) where the loose stools are not able to be clearly attributed to an underlying condition (eg inflammatory colitis, overflow) or therapy, (eg laxatives, enteral feeding) should have a sample sent to test for CDI. Assumptions that CDI is not the cause of new diarrhoeal episodes need to be robust and documented in the patient's notes. There should be a medical assessmentof such cases to assure that diarrhoea is not of infective origin. Any patient who has CDI detected from a faecal sample should not have repeat samples sent within 28 days. Where patients have a re-occurrence of diarrhoea that is more than 28 days from the last episode, they should have faecal samples sent to determine if this episode is a recurrence of CDI, unless the loose stools can be clearly attributed to an underlying condition or therapy (see above). The sample, when sent to the laboratory to test for CDI will be tested using either a glutamate dehydrogenase (GDH) or a toxin gene (PCR) test. If positive this determines the patient has a diagnosis of CDI and the CDI care pathway must be followed. For those patients that have a positive GDH or PCR test for CDI a further toxin test will be undertaken (Enzyme Immunoassay EIA or cytotoxin) test. If this test results as positive the patient will be entered onto against the trusts trajectory. If it is negative then the patient is still deemed to be CDI positive, but they will not be entered against the trusts trajectory. Regardless of whether the patient is entered against the trusts trajectory or not, following identification of a sample positive for CDI obtained within 2 days of admission to LPT (where day 1 is day of admission) a route cause analysis (RCA) should be undertaken by the clinical staff caring for the patient to assess the care provided to identify any areas for learning. (See Appendix 4). Guidance has also been given in Appendix 5 to aid staff to complete the RCA. Any learning should support the development of an action plan and subsequent improvement for care. The RCA and any subsequent learning and action plans need to be shared with all directorates within LPT to ensure that the trust as a whole can change practice or instigate further training where required to ensure that the same learning is not repeated Once the RCA has been completed by the staff based in the clinical area where the CDI was detected it should be sent to the IPC team. It may be necessary to hold a meeting to discuss the RCA. The decision to hold a meeting will be made by the IPC team and if required should include the following:

Ward Manager

ANP

Matron

Associate Director of Nursing

IPC

Pharmacy

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The completed RCA's will be presented to the CCG who will monitor the completion of any subsequent action plans. All CDI's that are deemed to be Serios Incidents according to existing national definitions (typically CDI's with identified lapses/learning in care that led to death or serious harm) must be reported to the Strategic Executive Information System (STEIS) and the 'lessons learned' field in STEIS should be updated once the investigation is completed within the mandatory timeline.

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5.0 Training There is no training requirement identified within this policy.

6.0 References and Associated documents Ahmed SM, Hall AJ, Robinson AE, et al, Global prevalence of Norovirus in cases of gastroenteritis; a systematic review and meta-analysis. Lance Infectious Diseases 2014; 14, 725 – 730 Daniel J, Cepeda JA, Cameron F, Cloy K, Wishart D, Templeton KE, Epidemiology and costs associated with Norovirus outbreaks in NHS Lothian, Scotland 2007-2009. Journal of Hospital Infection 2011; 79 354-358 DH Up-dated Guidance on the Diagnosis and Reporting of Clostridium difficile (2012) DH. Clostridium difficile infection objectives for NHS organisations in 2019/20 and guidance on the intention to review financial sanctions and sampling rates from 2020/21. NHSimprovements (2019) Health and Safety at Work Act 1974 Health and Social Care Act, DH 2008 Updated 2015 HPA, DH Clostridium difficile infection: How to deal with the problem. (2008) Howell MD, Novack V, Grgurich P, Soullaiard D, Novac L, Pencina M, Talmor D (2010).Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection .Arch Intern Med 170:784-90 Leicestershire Partnership Trust 2018, Cleaning and Decontamination. IPC. Leicestershire Partnership Trust, Hand Hygiene Policy (including Bare Below the Elbows) May 2019. IPC. Leicestershire Partnership Trust, Management of a Patient requiring source isolation 2018. IPC. Leicestershire Partnership Trust, Management of Waste 2017. IPC. Moments for Hand Hygiene (2009) National Institute for Health and Care Excellence (NICE) www.nice.org.uk Public Health England. May 2013. Updated guidance on the management and treatment of Clostridium difficile infection. Royal College of Nursing, 2013. The management of diarrhoea in adults. RCN guidance for staff. London World Health Organisation: Guidelines on hand Hygiene in Health care – The 5 moments of Hand Hygiene

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APPENDIX 1

TO HELP US PREVENT THE SPREAD OF INFECTIONS

SOURCE ISOLATION PRECAUTIONS

Everyone* entering this room must:

This applies to all staff entering the room whether or not

contact with the patient or environment is anticipated

Be “Bare Below the Elbows”

Wash their hands

Wear Gloves

Wear an apron

*Visitors do not need to wear an apron and gloves but must wash

their hands prior to entering and leaving the room.

Please speak to the nurse in charge for further advice

Please keep the door closed

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APPENDIX 2

Flowchart for the management of Patients with diarrhoea and/or

vomiting

Commence source isolation Precautions (SIPs) and Inform the IPC team. Refer

Patient with diarrhoea and/or diarrhoea and

vomiting Infective cause

considered?

NO YES

No source isolation precautions required

Investigations as necessary

Norovirus suspected CDT suspected

Patient to be placed in single room(ensure vacated bed space is cleaned)

Previous positive CDT result TREAT

No previous result - send sample for CDT and MC&S.

Commence appropriate paperwork

If faecal sample positive for CDT follow community prescribing guidelines

Do Not send ‘clearance’ samples for CDT

Do not move patient from a bay into a single

room.

Source isolate each patient in the bay.

Close the bay to

admissions

Refer to increased incident policy

Single room not available

Complete risk assessment

Nurse in bay with source isolation

precautions

Patient/s to remain in source isolation until they are all

48 hours asymptomatic and passing a stool that is

normal for them.

If results are negative a medical review needs to be

undertaken to ascertain the reason for loose stools

Post infection cleaned as required

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APPENDIX 4 Annex 1: Clostridium difficile infection case checklist This checklist was developed by the Public Health England CDI ‘Lapse in Care’ sub-group. The checklist can guide local assessment of CDI cases to capture the minimum information needed to determine the learning required to prevent it happening again. It should ensure a consistent approach to information in CDI case assessments across the whole health economy to identify recurring themes and reduce healthcare associated infections. It will also help you understand what your local co-ordinating commissioners will be looking for if you wish to discuss cases you consider occurred despite no lapses in care, as outlined in this guidance. 1.0 Local CDI assessment – what to include:

1.1 Hospital Data Capture System case number

1.2 Date of birth 1.3 Male/female 1.4 Date of current admission during which CDI was diagnosed 1.5 Initial reason for this admission, underlying conditions, and whether diarrhoea was present when admitted 1.6 The patient pathway should be clearly stated 1.7 Were any of the following risk factors for developing diarrhoea identified on admission or when

the specimen was taken, including:

• recent laxatives/enemas/anti-emetics/protein pump inhibitors • enteral nutrition • inflammatory bowel disease • previous gastrointestinal surgery • gastrointestinal malignancy • ileostomy/colostomy • other gastrointestinal infection, eg norovirus • chemotherapy/graft versus host disease • other immunosuppressive illness or therapies, eg steroids.

1.8 Was bowel habit recorded on admission? Was the Bristol stool chart (BSC) used? Was it used

immediately when symptoms began? Summarise the BSC results. Were other measures used to monitor for the presence of diarrhoea in this patient?

1.9 On what date were diarrhoeal symptoms first documented in relation to the current episode of

CDI? Was the patient source isolated at the time? If no, how soon after onset of diarrhoeal symptoms was the patient source isolated? What was/were the reasons for delay in source-isolation? If there is insufficient information available to determine the timeliness of interventions, then this is a potentially important shortcoming.

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1.10 On what date and in which location was the sample taken? Was there a delay in sampling

according to your local guidance? As a minimum, national guidance should have been followed. 1.11 On what date and at what time was the sample received in the laboratory? On what date and at

what time was the result was reported to the sender? 1.12 Were the sampling, testing and reporting arrangements in this case clearly compliant with the

2012 Department of Health (now Department of Health and Social Care) guidance Updated guidance on the diagnosis and reporting of Clostridium difficile?

1.13 How long did the patient remain under appropriate source-isolation after the CDI diagnosis? If

the patient was removed from source isolation what was the rationale? Was this consistent with your local guidance?

1.14 If there was any non-compliance above – explain why. 2.0 Chronology of patient pathway 2.1 Provide an outline timeline where the patient was in the three months prior to the latest CDI

diagnosis, eg home, hospital, care home, etc. Ideally, identify if they had any contact with known CDI cases or carriers of C. difficile (eg GDH- positive, toxin-negative cases) in these locations and, if so, any relevant ribotyping/MLVA results that are available.

2.2 Had the patient had any previous confirmed episodes of CDI? If yes, when did they occur? If

performed, what are/were the ribotyping/MLVA typing results of the current and any past episodes of CDI? Had the patient been told of the CDI diagnosis and understood the condition?

2.3 If you suspect that the latest case is a recurrence, outline if the previous episode(s) were

correctly treated as per your local CDI treatment guideline. Was the patient treated with any other antimicrobials between this and the previous episode(s)? Was this treatment in line with local guidelines?

2.4 Has the patient received other treatment (eg enteral feeding) and/or medication (eg proton

pump inhibitors) possibly relevant to the development of this episode of CDI? Were these in line with local guidelines?

2.5 If there was any non-compliance above – explain why. 3.0 Antimicrobial therapy 3.1 List all antimicrobial therapy (antibiotic, dose, duration) in the previous 12 weeks. 3.2 Concerning the current episode/admission, were the indication(s) for antimicrobial treatment

duration and the review date written in the patient’s notes or drug chart? Was the indication(s) for this treatment appropriate at the point it was prescribed?

3.3 Was initial empiric therapy appropriately modified in response to microbiological results? 3.4 Were all antimicrobials prescribed compliant with local guidelines? If not, were they still clinically

justified (please provide an explanation)? 3.5 If there was any non-compliance above, explain why.

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4.0 Treatment of CDI and outcome 4.1 Was the patient treated for CDI on this occasion? If not, what were the clinical factors that were

used to determine treatment was not required? 4.2 Was the patient told of the CDI diagnosis and did he/she demonstrate an understanding of the

condition? 4.3 Does your local CDI treatment guideline contain a measure of severity? If so, how was this case

categorised? 4.4 If this case was treated, what treatment (drug, dose, duration) was used? Was this treatment compliant with your local guidance? 4.5 What was the clinical outcome? Did the patient die within 30 days of CDI diagnosis? If so, was

this death linked to CDI? Did CDI appear on the death certificate (which part); please provide details of all conditions listed?

4.6 If there was any non-compliance above – explain why 5.0 Environmental factors 5.1 Were there any cleanliness/environmental issues reported in relation to the area(s) in which the

patient was cared for prior to the development of CDI (including the results of recent audits)? Please provide details of any issues.

5.2 Outline details of any additional cleaning measures that have been deployed in this/these

area(s) over the previous three months (eg hydrogen peroxide vaporisation) either as a pre-emptive measure (eg whole ward decant/deep clean) or as terminal side room cleaning in relation to previous episodes of CDI.

5.3 What audit/monitoring measures were in place to assess the efficacy of cleaning? How robust

(quantitative/qualitative) are these? 5.4 What monitoring of hand hygiene compliance was in place at the time including how robust this

monitoring was, eg who did this? What were the results? 5.5 If there was any non-compliance above, explain why. 6.0 Organisation issues 6.1 Were there any organisational factors that might have influenced this case? This could include

whether staffing levels/skill mix were in line with local agreements where this patient was managed.

6.2 Is there evidence that mandatory training and infection, prevention and control training have

been undertaken by staff relevant to this case? 6.3 Is there evidence that communication and documentation related to this patient was adequate? 6.4 If there was any non-compliance above, explain why and how this could /

could not be related to the development of C. difficile infection.

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7.0 Optimisation of diarrhoea control in the organisation 7.1 Does the organisation have a protocol for the management of patients with diarrhoea? Was this

being followed in the clinical area relevant to this case? More specifically: 7.1.1 Was the documentation of patients with diarrhoea adequate/complete? 7.1.2 Was the rate of diarrhoea increased in the clinical area relevant to the index case (during the 1

month beforehand)? Was a reason for this found and what measures were put in place to address this? Were these patients managed in accordance with local guidance in relation to sampling and source isolation of suspected infectious causes of diarrhoea?

7.2 If there was any non-compliance above, explain why. 8.0 Lessons learned 8.1 Outline the lessons learned from this episode of CDI. Are there any recurring themes seen

across this and other assessments? How have these been addressed? 8.2 Provide a commentary on any recurring themes from previous CDI case assessments. What is

the hypothesis for why these cases are still happening? What action(s) has the organisation put in place to prevent further cases of CDI? What factors appear to be responsible for their lack of success?

9.0 Preventability 9.1 State whether you have identified any learning that could have contributed to the development

of this CDI case. 9.2 To facilitate learning and optimisation of patient care, please identify any other lapses in care, ie

that did not contribute to the development of this CDI case. 9.3 If you consider this CDI case occurred despite no lapses in care (and so was

deemed not to be ‘preventable’), outline your reason(s) why.

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Appendix 5

1. Demographics

Patient identifier (HDCS Case Number)

Date of Birth

Gender

Date of specimen

Date of current admission

Ward or Department

Reason for Admission (state if patient admitted with diarrhoea )

Brief description of any underlying condition, treatment, previous CDI episode and current progress

Is this infection classified a new, a relapse or repeat within episode?

2. Clostridium difficile infection

Inflammatory markers at time of specimen collection

White cell count

CRP

Temperature

Risk factors for developing diarrhoea identified on admission or at the time of specimen collection

Recent laxatives / enemas

Anti-emetics

Proton pump inhibitors (PPI)

Enteral nutrition

Inflammatory bowel disease

Previous gastrointestinal surgery

Gastrointestinal malignancy

Ileostomy / colostomy

Other gastrointestinal infection such as norovirus

Chemotherapy / graft versus host disease

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4. Isolation and sampling

Was the patient's bowel habit recorded on admission?

Was the patient monitored using the Bristol Stool chart (BSC) immediately

when symptoms of diarrhoea (BSC -T5, T6 and T7)began?

Date diarrhoeal symptoms were first documented in relation to the current

episode of CDI?

Was the patient isolated at the time of onset?

If no, how soon after onset of diarrhoeal symptoms was the patient isolated?

Date sample was taken

Location of patient when sample taken

Date/time the sample was received in the laboratory

Date/time the result was reported to the sender

Was there a delay in sampling according to local guidance?

Were isolation precautions discontinued inline with local policy ?

Were sampling, testing and reporting arrangements clearly compliant with 2012

DH ‘Updated guidance on the diagnosis and reporting of C. difficile’?

If there was any non-compliance with above - explain why?

Other immunosuppressive illness or therapies such as steroids

Other risk factors

On review was it felt that this reflected a case of CDI?

Was the diagnosis communicated to the patient?

Did the patient demonstrate an understanding of the condition?

Was the infection measured by severity?

(mild/moderate/severe/life threatening)

3. Chronology of patient pathway

State previous admissions to any healthcare institution in the previous three months

Did the patient have any contact with known CDI cases in the

locations you have listed above?

Has the patient had any previous confirmed episodes of CDI?

Has ribotyping/MLVA typing been performed on the current

episode of CDI?

If the latest episode is a suspected recurrence, were previous

episode(s) treated as per local CDI treatment guidelines?

Was the patient treated with any other antimicrobials between this

and the previous episode(s)?

Was treatment in line with local guidelines?

Has the patient received other treatment / medication listed in

section 2 relevant to the development of this episode of CDI?

Were these in line with local guidelines?

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5. Antimicrobials

List all antimicrobials prescribed over the last three months with indication, duration and review dates

Were all antimicrobials compliant with local guidelines or clinically justified and

reasonable?

Was/were the indication(s) for antimicrobial treatment , duration and a review

date written in patient's notes/drug chart?

Was initial empiric therapy appropriately modified in response to

microbiological results?

If there was any non-compliance to above, explain why

6. Treatment of CDI and patient outcome

Was the patient treated for CDI?

Was the treatment in line with local guidance?

What was the clinical outcome? Recovered; PMC; Toxic megacolon; Colectomy

Did the patient die within 30 days of CDI diagnosis?

If so, was this death linked to CDI?

Did CDI appear on the Death Certificate?

Provide details of all conditions listed on death certificate

7. Environmental Factors

What audit/monitoring measures were in place to assess the efficacy of

environmental cleaning?

What is the most recent environmental cleaning scores? Provide date

Provide details of cleanliness/environmental issues reported in the area(s) in

which the patient was cared for prior to the development of CDI

What is the most recent hand hygiene audit results? Provide date

If there was any non-compliance to above, explain why

8. Organisational issues

Is there evidence that mandatory training and IPC training have been

undertaken by staff relevant to this case?

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10. Lessons Learned Outline the lessons learned from this episode of CDI. Are there any recurring themes seen across this and other CDI assessments?

How has the learning been addressed?

Provide a commentary on any recurring themes from previous CDI case assessments. What is the hypothesis for why these cases are still happening?

What interventions has the organisation put in place to prevent further cases of CDI?

What factors appear to be responsible for their lack of success?

Is there evidence that communication and documentation related to this patient

was adequate?

Are staffing levels/skill mix in line with local agreements where this patient was

managed?

If there was any non-compliance above, explain why and how this could / could

not be related to the development of CDI

9. Optimisation of diarrhoea control in the organisation

Does the organisation have a protocol for the management of patients with

suspected infectious diarrhoea (BSC T5, T6 and T7)?

Was this being followed in the clinical area relevant to this case?

Was the documentation of patients with diarrhoea adequate/complete?

Had the rate of diarrhoea increased in the clinical area relevant to the index

case during the 1 month beforehand?

Was this appropriately investigated and controlled?

What measures were put in place to address this?

If there was any non-compliance above – explain why

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11.Preventability

State whether you have identified any ‘lapses in care’ that could have contributed to the development of this CDI case

In order to facilitate learning and optimisation of patient care, please identify any other lapses in care that did not contribute to the development of

this CDI case

If you consider this CDI case occurred despite no lapses in care (and so was deemed not to be ‘preventable’), outline your reason(s) why

12. Summary of meeting with Commissioners

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Contribution List Key individuals involved in developing the document

Name Designation

Amanda Hemsley Lead Infection Prevention and Control Nurse

Antonia Garfoot, Mel Hutchings Andy Knock

Infection Prevention and Control Team

Circulated to the following individuals for consultation

Name

Designation

Anne Scott Interim Chief Nurse

Emma Wallis Associate Director of Nursing and Professional Practice

Sarah Latham Lead Nurse, CHS – Inpatient areas (physical health)

Laura Belshaw Lead Nurse, CHS – MHSOP

Rebecca O’Brien Lead Nurse, FYPC

Jane Martin Matron

Claire Armitage Lead Nurse, AMH&LD - Community

Michelle Churchard- Smith

Head of Nursing, AMH&LD – Inpatient Interim Deputy Chief Nurse

Katie Willetts Senior Nurse, Specialist nursing team

Kam Palin Occupational Health Nurse

Tejas Khatau Lead Pharmacist for FYPC

Bernadette Keavney Head of Health and Safety, Security

Tracy Yole Lead Nurse, CHS - Community

Sally Smith Senior Zone Coordinator

Helen Walton Property Manager, Estates and Facilities