A robust outbreak escalation process has helped a trust cut Clostridium difficile cases by 50 per cent in the past year. Em Wilkinson-Brice and colleagues explain how it was done
In early 2006, Derby Hospitals foundation trust conducted a root cause analysis following an outbreak of Clostridium difficile. Critical analysis led to improvements in the way the trust responds to further outbreaks, and in the ongoing management of the bacteria.
Our approach is based on team-working across a range of disciplines including nursing, infection control, medicine, communications, pharmacy, patient advice and liaison services, facilities and patient information. A critical success factor has been the engagement of lead clinicians - both doctors and nurses - from the affected areas. Clear leadership from clinical managers and more locally from the clinical areas have resulted in the creation of an efficient operating framework.
This allows clinical and operational decisions to be responsive to the current situation. Communication reaches all relevant departments and permeates through the organisation to the 'shop floor'.
The trust's 2006 outbreak plan outlines the criteria for establishing an outbreak control group, based on the theory of escalation. When we experienced a rising incidence of C difficile cases in September, the escalation process triggered the formation of the outbreak control group, which meant weekly multi-professional review meetings.
The trust is spread over two sites. The newer estate has the advantage of more side-room capacity, which means it is easier to isolate infectious patients. At the older site, one ward became an isolation ward.
Over 24 hours, patients without diarrhoea were moved to other wards, and known or suspected C difficile cases were transferred to the isolation ward. Confirmed cases and suspected cases were nursed in separate bays. Admission to the ward was managed by the infection control team. Patients could not be moved from the isolation ward to other wards or to care homes unless they had been free of diarrhoea for more than 72 hours, or there was an overriding clinical need. Unnecessary traffic was avoided.
Intensive cleaning regimes with bleach chlorite solution were introduced. Hand hygiene was maintained by washing with soap and water after each patient contact.
Communication between microbiology, infection control, lead clinicians and the trust's operational management personnel was crucial. Daily surveillance by the infection control team, communicated at the twice-daily bed meetings, ensured that C difficile patients were placed in appropriate beds. From a microbiological perspective, key success factors include:
- -Microbiologists phoning every positive result to the junior doctor and advising on changes of antibiotic treatment to narrow-spectrum agents, treatment of C difficile and hand hygiene.
- If there are three or more cases on a ward at any one time, e-mailing consultants who have patients on that ward and informing them of changes in antibiotic prescribing to narrow-spectrum agents.
- Writing an alternative antibiotic guideline and advice on treatment of primary C difficile and recurrent C difficile, in consultation with gastroenterologists.
We also set up a partnership with the public through written information explaining C difficile and the measures put in place to manage the situation.
Good teamworking has extended across the local health community to include PCTs, GPs, nursing and residential homes. We have begun to strengthen our relationship with social care and the wider nursing home network.
The trust has developed a robust outbreak escalation process with key personnel involved at every stage. There is an increased awareness in the organisation of how reducing C difficile and other healthcare-associated infection is everybody's business. The prevalence of C difficile has dropped by 50 per cent since the introduction of these measures. -
Em Wilkinson-Brice is deputy director of nursing, Rob Skelly consultant physician, Selina Hoque consultant microbiologist and director of infection prevention and control, and Kay Fawcett director of nursing at Derby Hospitals foundation trust.