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DN226 Clostridium difficile (C. diff) - Procedure
DN226 Clostridium difficile - Procedure Version: 6 Review due: April 2020
Page 1 of 17
Document title:
Clostridium difficile Procedure
Document number:
DN226
Staff involved in Development (job titles):
Consultant Microbiologist
Infection Prevention and Control Nurse Specialist
Document author/owner: Consultant Microbiologist
Infection Prevention and Control Nurse Specialist
Directorate: Nurse Management
Department: Infection Prevention and Control
For use by: All clinical staff
Review due: April 2020
This is a controlled document. Whilst this document may be printed, the electronic version maintained on the Trust’s Intranet is the controlled copy. Any printed copies of this document are not controlled. ©Papworth Hospital NHS Foundation Trust. Not to be reproduced without written permission.
Key points of this document: Guidance on management of hospital inpatients with Clostridium difficile. Roles, responsibilities and measures to be undertaken to identify, treat and limit
spread. Monitoring and audit.
DN226 Clostridium difficile (C. diff) - Procedure
DN226 Clostridium difficile - Procedure Version: 6 Review due: April 2020
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Contents
Key points of this document: ................................................................................................................. 1
1. Introduction ................................................................................................................................ 3
2. Clinical Definitions and Laboratory Diagnosis ............................................................................ 3
3. When to Send a Sample for C. difficile Toxin Testing ................................................................ 3
4. Management and Treatment of C. difficile Infection (CDI) .......................................................... 5
5. Infection Control Precautions ..................................................................................................... 5
6. Environmental and Equipment Cleaning .................................................................................... 6
7. Transfer/discharge of C. difficile Positive Patients ...................................................................... 7
8. Advice for Visitors ...................................................................................................................... 7
9. C. difficile Outbreaks ................................................................................................................. 7
10. Death Certification ..................................................................................................................... 8
11. Risk Management / Liability / Monitoring & Audit ............................................................................. 8
Appendices ...................................................................................................................................... 9-15
DN226 Clostridium difficile (C. diff) - Procedure
DN226 Clostridium difficile - Procedure Version: 6 Review due: April 2020
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1. Introduction Clostridium difficile (C. difficile) is a common pathogen in older people with an asymptomatic carriage rate between 2-20%. The spectrum of C. difficile associated disease (CDAD) ranges from asymptomatic carrier status through clinical diarrhoea to fulminant colitis and toxic megacolon. Antibiotics have commonly been associated with CDAD but are not the only risk factor. Other associations include exposure to antineoplastic agents, gut motility altering drugs, surgery and chronic illnesses. The ability of C. difficile to produce spores enables the organism to survive in the environment. Faecal-oral transmission allows colonisation of the gastro-intestinal tract. Disruption to the host’s normal bowel flora allows C. difficile to multiply in the colon. Toxins are produced which, on binding to target cells in the colon, cause damage to these cells resulting in inflammation and mucosal injury. Prevention relies on reducing exposure to risk factors so as to limit disruption of host bowel flora. Infection control measures are important in limiting spread. CDAD is of great clinical importance as a cause of hospital acquired diarrhoea and is undergoing an apparent change in epidemiology and disease patterns. A recent United Kingdom outbreak involving C. difficile serotype 027 was investigated by the Healthcare Commission. Serotype 027 is associated with a higher morbidity and mortality where strict infection control practices are paramount in limiting spread. The Department of Health / Health Protection Agency guidance recommends that doctors consider C. difficile infection (CDI) as a diagnosis in its own right, grading each confirmed case for severity, treating accordingly and reviewing each patient daily, monitoring bowel function using the Bristol Stool Form Scale. 2. Clinical Definitions C. difficile case: one episode of diarrhoea (Bristol Stool Form Scale 5-7) that is not attributable to any other cause, with a positive toxin assay. A period of increased incidence: two or more cases in a 28 day period on a ward area. C. difficile outbreak: 2 or more cases caused by the same strain related in time and place. A C. difficile equivocal result for a patient will be managed on an individual basis by the team concerned and the IPC team; however, all rooms which have housed C. diff equivocal patients must be cleaned with Hydrogen Peroxide Vapour (HPV) on patient discharge/transfer from side room. 3. When to Send a Sample for C. difficile Toxin Testing
Commence a chart for the Management of patients with loose stools in the patient’s notes
(ND28 immediately after a new episode of diarrhoea (Bristol Stool Form Scale 5-7). Send a sample of faeces for C. difficile testing as soon as infective diarrhoea is suspected, for
example if the patient has raised White Blood Cell Count (WCC), raised CRP,raised serum creatinine, or abdominal pain or distension.
The sample should also be requested for routine culture and norovirus testing where appropriate. To request testing for C.difficile the C.difficile box on the form must be ticked/requested
appropriately on Ordercomms, otherwise the sample will not be tested. Attach all generated Ordercomms stickers for the sample to the container. The sample must be requested as urgent and placed into microbiology red bag.
Sending the sample to the lab-
DN226 Clostridium difficile (C. diff) - Procedure
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In hours, send the sample to the Papworth Laboratory & ring the Lab Reception on Ex 4321 to inform them that the urgent sample is coming.
Out of hours, contact Addenbrookes switchboard and ask to be put in contact with the on call Microbiology Biomedical scientist, to inform them that the sample is coming and it needs to processed as urgent. The sample will need to be taxied over to the Addenbrookes lab. Taxi to be arranged by the ward sending the sample, with input from Senior Nurse or Matron on duty.
Do not send a sample after the first episode if there are other potential causes of diarrhoea including recent laxatives AND there are no other signs of CDI such as abdominal pain, abdominal distension or high WCC. The suspected cause for the diarrhoea, if not thought to be infective, must be documented on the front of the chart
If CDI without diarrhoea (toxic megacolon, pseudomembranous colitis) is suspected, other diagnostic methods such as colonoscopy or abdominal CT (computed tomography) may be required.
If after referring to the Management of patients with loose stools flow chart, you are still unsure of whether to send a sample please contact the Infection Prevention and Control Team (IPCT).
Laboratory Testing Testing for C. difficile toxin is available 7 days per week. The laboratory will communicate positive
results to the ward as they become available. There is no need to re-test for C. difficile toxin once in receipt of a positive result. There is no need to test for ‘clearance’, as C.difficile toxin can remain in the gut for many months.
The patient will be deemed no longer infectious based upon clinical presentation, i.e. Type 1-4 stool for 72 hours.
If further testing is required, then please discuss with microbiology. Actions on receipt of positive C. diff result The result will be telephoned immediately by the microbiologist to the patient’s clinical team, so that clinical management can be discussed. This includes out of hours and bank holidays. If clinical advice is required then the clinical microbiologist should be contacted including out of hours. The Infection Prevention & Control nursing team will inform the ward staff by telephone as soon as the result is available, during normal working hours (Mon-Fri), so that treatment and control measures are instituted promptly. The Infection Prevention Nurse will visit the patient within 24 hours of the result becoming available (during normal working hours, Mon- Fri) to explain the organism and offer advice and reassurance. High Impact 7 for C. diff should be completed for 20 observations (see Appendix D) and the C. diff care bundle (Appendix E) should be commenced and continued until the patient is discharged or no longer isolated.
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4. Management and Treatment of C. difficile Infection (CDI) SIGHT Doctors and Nurses should apply the following mnemonic protocol when managing suspected potentially infectious diarrhoea: S Suspect that a case may be infective where there is no clear alternative cause for diarrhoea. I Isolate (if unable to do this within 2 hours escalate the problem and consult with the Infection Control Team. 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 the patient’s environment. T Test the stool for toxin, by sending a specimen immediately, if clinically indicated. Clinical management of the patient with CDI Commence C. difficile integrated care bundle (see appendix A). Monitor and record daily for frequency and severity of diarrhoea using the Bristol Stool Scale. Review and stop any unnecessary antibiotics. Stop any laxative treatment. Review the use of Proton Pump Inhibitors with a view to stop or reduce the dose as clinically
indicated. Manage patients with CDI as a diagnosis in its own right. Each patient to be reviewed by the medical team on a daily basis regarding fluid resuscitation,
electrolyte replacement, abdominal signs, nutrition and severity of disease and findings to be recorded in the medical record.
The IPCT will review all patients with CDI at least weekly and liaise with the clinical team accordingly.
Consider use of faecal management system - risk assess in consultation with Infection Prevention and Control nurse.
Refer to Appendix B for treatment of CDI.
Information for Staff and patients An information leaflet on C. difficile is available to staff and patients on the intranet and must be given to all patients who are diagnosed as C. difficile positive.
5. Infection Control Precautions
See separate procedure DN611 for patients on ICU and PCU All patients with type 5-7 stools should be moved into a single room with clinical hand wash
facilities and a self-contained toilet within two hours of the second episode and enteric precautions observed. If a single room is not immediately available refer to Trust Procedure Isolation room: Priority for use DN317 and then this should be recorded by the nurse in charge and fed back to the Infection Prevention and Control Team. Until a room becomes available, the patient should be nursed in the bay using strict enteric precautions. The reason for the delay must be documented in the clinical notes.
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The Green isolation sign (enteric precautions) should be placed on the door to the single room. The isolation room door must remain closed unless an appropriate reason is documented by the nursing/medical team in the clinical notes. Where possible an alternative solution should always be sought to prevent the door from remaining open.
Patients should have their own toilet or dedicated commode. Dedicated equipment should be used in the room i.e. blood pressure cuffs, stethoscopes, drip
stands and not shared with other patients without thorough cleaning and disinfection. Bed sheets and nightwear should be changed when soiled and at least daily and treated as
infected linen. All staff entering an isolation room containing a patient with type 5-7 stools as defined by the
Bristol Stool Scale, should wear disposable aprons and gloves when entering the room. Personal protective equipment should be removed prior to leaving the room and treated as clinical
waste. Hands should be washed with soap and water after removal of PPE and again after exiting the
room. Please note: Alcohol hand gel is ineffective in destroying Clostridial spores and must not be used when caring for patient with C. difficile
Fans should not be used within the room. All waste/linen to be treated as infected waste and removed and disposed of in a timely manner.
Refer to DN375 Waste Management Policy. The patient should remain isolated in the side room until they have been asymptomatic for 72
hours and passed type 1-4 stool in accordance with the Bristol Stool Scale. The patient’s room must then be final cleaned with a chlorine/ sporicidal based productonce type
1-4 stool for 72 hours have been recorded, if they are to remain in the same single room (Refer to the Trust Cleaning & Disinfection procedure DN11/ Isolation Procedure DN89).
In the event of a relapse or recurrence of C. difficile disease then the patient should again be
isolated in a single room. There is no need to send further stool samples. Treatment to be decided by the clinical team in conjunction with the Microbiologist.
6. Environmental and Equipment Cleaning Refer to Trust Cleaning and Disinfection Procedure DN11/ Isolation Procedure DN89.
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7. Transfer/Discharge of C. difficile Positive Patients Avoid transfer of infected patients to other wards/departments unless required for clinical need
and only after discussion with the receiving area, these patients should be moved to the end of the list wherever possible and safe to do so.
For transfer to other wards and healthcare providers the receiving area should be notified of the patient’s CDI status in advance of the transfer. Please refer to the Discharge and Transfer procedure DN96.
When discharging a patient who has been positive for C.difficile on the current admission, ensure that it is clearly documented on the patient’s e-discharge letter. This will aid the GP for ongoing care of the patient including the prescription of antibiotics in the future.
The room must be HPV cleaned once the patient has been discharged or moved out of the room even if they have been asymptomatic. A note/reminder should be kept on the ward for these cases so that the clean is remembered. ISS should be informed of the need for a HPV clean as soon as practically possible to enable them to facilitate this.
8. Advice for Visitors
All visitors entering an isolation room containing a CDI patient should use disposable gloves and aprons for all clinical contact with the patient and the patient’s environment. Visitors must be advised to wash their hands with soap and water on entering and leaving the room. 9. C. difficile Outbreaks Where two or more hospital acquired cases (i.e. who develop symptoms more than 48 hours after
admission) are linked by time and location (over and above the usual background rate) the infection control team will investigate a potential outbreak.
Samples from affected patients will typed by the laboratory. An outbreak committee will be set up as outlined in Appendix C. A decision to open a dedicated isolation ward will be made by the outbreak committee in the event
that numbers of affected patients exceeds the number of side rooms available In the event of a confirmed or suspected C. difficile outbreak, then it may be necessary to cohort*
patients in a bay with isolation nursing procedures.
*cohort is when several patients with the same disease are isolated together by a team of nurses who do not care for
other patients on the ward.
A C. difficile outbreak will be confirmed if 2 or more cases caused by the same strain are related in time and place.
A C. difficile outbreak must be reported as a Serious Incident (SI) In the event of a confirmed outbreak, the outbreak committee will communicate to the Trust board,
Health Protection Agency and the Strategic Health Authority. 10. Death Certification If C difficile is entered on a Death Certificate in Part 1 (i.e. if CDI was part of the sequence of events leading directly to death or was the underlying cause of death) then the certificate must be completed by the patient’s Consultant and the death must be reported as a Serious Incident (SI).
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If a doctor is in doubt about the circumstances of death when writing the certificate, they should consult with the Infection Control Doctor or Consultant Microbiologist. 11. Risk Management / Liability / Monitoring & Audit
Please refer to the monitoring table in DN15 which shows the mechanism for monitoring the controls assurance framework in place for infection prevention and control at Papworth Hospital. The Infection Prevention & Control Committee is responsible for developing measurement tools, reviewing/monitoring practice and instituting action plans as necessary. A monthly surveillance of patients requiring isolation will be undertaken by the Infection Prevention & Control nurses to ensure that the appropriate control measures are taken. For guidance on the priority use of side rooms refer to DN317. A root cause analysis will be carried out by the infection prevention and control team in conjunction with the clinical team for all cases of CDI. The root cause analysis is then reported to the consultant in charge of the patient and to the infection prevention and control committee. An audit of compliance against High Impact Intervention 7 will be completed by staff in the affected ward with support from the Link Practitioner for that ward and the Infection Prevention & Control Team. This will ensure that the appropriate control measures are taken for all cases of CDI. See appendix D. 12. References PHE Updated guidance on the management and treatment of Clostridium difficile infection. 2013 Department of Health: Clostridium difficile infection: How to deal with the problem (2008)
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C. difficile Outbreak Suspected
Nurse in charge to contact the Infection Control Nurse (bleep 186) or Senior Nurse (out of hours). They will discuss the
problem with the Microbiologist.
Senior Nurse (out of hours) will inform the On call General Manager.
WARD CLOSED TO ADMISSIONS, TRANSFER OF PATIENTS TO OTHER WARDS, HOSPITALS AND NURSING HOMES.
PATIENTS CAN BE DISCHARGED HOME.
F I R S T
P H A S E
S E C O N D
P H A S
E
Responsibilities
Nurse in Charge:
Inform:
■ Other patients ■ Relatives/visitors ■ Senior Nurse
Implement Guidelines
Infection Control Nurse or Nurse Manager (out of hours): ■ Inform Domestic supervisor ■ Put up outbreak posters Next normal working day: ■ E-mail All Users regarding
ward closure ■ Inform:
■ Health Protection Unit ■ Hotel Services Manager ■ PALS
On confirmation of the outbreak
Report the outbreak as a serious incident (liaise with Risk Manager)
Microbiologist: ■ Consider need for
outbreak meeting ■ Arrange for samples
to be saved for sending to the Ref Lab.
■ DIPC
Senior Nurse: Inform: ■ Medical staff ■ Bed Manager ■ Directorate
Manager(s) ■ NHS Professionals /
other agencies
DIPC: Inform: ■ Chief Executive ■ Medical Director ■ Risk Manager ■ Director of
Operations ■ Media (if required)
Appendix A – Outbreak Management
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Appendix B – Audit Tool
Clostridium difficile review tool (Saving Lives High Impact Intervention No. 7) Aim: To reduce the risk of infection from and the presence of Clostridium difficile
Regular Observations
Care bundle to reduce the risk from Clostridium difficile: Prevention of spread - Review tool
Observation
Elements Are all elements
compliant? (fills in
automatically)
Prudent antibiotic prescribing
Correct hand hygiene
Environmental Decontamination
Personal Protective Equipment
Isolation/Cohort Nursing
1
2
3
4
5
6
7
8
9
10
How to use this review tool Indicate ‘YES’ when the element was performed or considered not applicable and ‘NO’ to show that it was not performed. • The tool is designed to facilitate rapid feedback for improvement and should be repeated at regular intervals to gauge progress • The objective is to ensure that all elements of the clinical process are performed all of the time • The percentage compliance gives an indication of which particular element needs attention
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Appendix C
ENSURE NAME, DESIGNATION, SIGNATURE, INITIALS AND DATE ARE DOCUMENTED ON THE MAIN DOCUMENTATION FOR THE PATIENT AND INITIAL UNDER DATE/TIME COLUMN EACH TIME TASK IS COMPLETED. Ward: IMMEDIATE ACTION DAY 1
Ward:
ACTION DATE/TIME INITIALS
Date of onset of suspected infective diarrhoea
Date toxin positive stool specimen result received
Date/time patient isolated into single room, enteric sign (within 2 hours of second episode of diarrhoea as per DN226)
Medical team informed and treatment algorithm started (see below)
Patient/relatives informed and information leaflet given
Stop laxatives
Stop anti-motility agents
Inform domestic manager
Inform antibiotic pharmacist
Inform dietician
CLOSTRIDIUM DIFFICILE (C. DIFF) Care Bundle
Name: Date of birth: Hospital number: NHS number: Consultant:
CLOSTRIDIUM DIFFICILE (C. DIFF) Care Bundle
Name: Date of birth: Hospital number: NHS number: Consultant:
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Date (DD/MM/YY)
Time – use 24 hour clock
Hand hygiene: every patient care episode with soap and water only
Personal protective equipment: every patient care episode
Stool chart: Ensure stool chart completed
Isolation: Ensure enteric precautions sign in place and door closed
Environmental cleaning: Performed with chlorine-based product or sporicidal wipes if clinically indicated
Prudent prescribing: Ensure antibiotics and (PPIs) are regularly reviewed
Medical team review: Ensure carried out daily
Ward
CLOSTRIDIUM DIFFICILE (C. DIFF)
Care Bundle
Name: Date of birth: Hospital number: NHS number: Consultant:
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Variance code
Descriptor If an episode of care occurs which is not covered in the care bundle, details must be documented in the medical notes.
RA Patient has mental capacity but has refused assessment and/or will not comply with agreed plan of care
MC Patient does not have mental capacity to comply
SC Carers not implementing plan
SR Unable to isolate within timescale – single room not available
Date and time
Record element Code Reason for not delivering care Initials
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Appendix D Figure 1 - Treatment Algorithm for primary treatment regimens
(adapted from C. difficile: How to deal with the problem. DH 2008)
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Figure 2 - Treatment algorithm for recurrent CDI
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Further document information
Approved by Executive Director/local committee (required for all documents):
Infection Prevention and Control Committee
Minor amendments by Chair’s Action 02/2012
Approval date (this version):
04/2020
Approved by Board of Directors or Committee of the Board (required for Strategies and Policies only):
N/A
Date: N/A
This document supports: standards and legislation – include exact details of any standards supported
2008 DH, HPA. C. difficile Infection: How to deal with the problem
2008 Department of Health. (2008 updated July 2015) The Health and Social Care Act: Code of Practice for the prevention and control of healthcare associated infection.
2010 DH “Saving Lives” High Impact Intervention No.7
2007 HCC Stoke Mandeville Report
2009 Care Quality Commission Core Standard C4(a)
2013 Updated guidance on the management and treatment of Clostridium difficile infection. Public Health England. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317138914904
Key related documents: Isolation Procedure DN89
Personal Protective Equipment DN441
Cleaning and Disinfection DN 11
Transfer and Discharge Procedure DN96
Isolation room: Priority for use DN317
Management of Inpatient with Loose Stool ND28
Hand Hygiene Procedure DN009
Equality Impact Assessment: Does this document impact on any of the following groups? If YES, state positive or negative, complete Equality Impact Assessment form from DN507 Single Equality Scheme, and attach.
Groups: Disability Race Gender Age Sexual orientation
Religious & belief
Other
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Yes/No: No No No No No No No
Positive/ Negative:
N/A N/A N/A N/A N/A N/A N/A
Counter Fraud In creating/revising this document, the contributors have considered and minimised any risks which might arise from it of fraud, theft, corruption or other illegal acts, and ensured that the document is robust enough to withstand evidential scrutiny in the event of a criminal investigation. Where appropriate, they have sought advice from the Trust’s Local Counter Fraud Specialist (LCFS).