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					                                    Richmond & Twickenham Primary Care Trust




                        PREVENTION & MANAGEMENT
                                   OF
                          CLOSTRIDIUM DIFFICILE
                               GUIDELINE

POLICY REFERENCE

DATE RATIFIED AND
 VERSION NUMBER
   SUBSEQUENT
RATIFICATION DATE
NEW REVIEW DATE                                    November 2009




                               ACCOUNTABLE DIRECTORS
                                    Sinead O’Brien


                                         CHIEF EXECUTIVE
                                            Joan Mager


                                         POLICY AUTHORS
                                           Shona Ross




Issue Date: 10.01.08                                                           Version No. 2.0
File: Prevention & management of Clostridium difficile Guideline               Page 1 of 19
                                    Richmond & Twickenham Primary Care Trust




Consultation List

Clinical Action Team Members

Viv Bignell                             Clinical Governance Facilitator
Liza Coghill                            Community Hospital Clinical Services Manager
Jill Downey                             Associate Director Community Hospital Services
Linda Hagan                             Professional Lead for Universal Children & Family Services/
                                        Surrey Children and Family Services Manager
Syed Hussain                            Risk Manager
Judith Kay                              Middlesex Adult Services Manager
Carol Keys-Shaw                         Associate Director Children & Family Services
Lesley McLennan-Yeo                     Director of Community Health Services & Estates
Jane Nicoli-Jones                       Surrey Adult Services Manager/ Professional Lead Adult
                                        Nursing
Karen Page                              Head of Therapies/ Professional Lead Therapy Services
Trisha Roe                              Professional Lead for Targeted Children & Family Services/
                                        Middlesex Children & Family Services Manager
Rosie Smith                             Community Services Pharmacist
Anne Stratton                           Associate Director for Older People & Adults
Shelagh Waterer                         Clinical Governance Facilitator


Health & Safety & Infection Control Committee Members

Banu Gajendran                          Health & Safety Manager
Shelagh Eaton                           Associate Director Performance
Doug Fuller                             Associate Director Estates & Facilities
Louise Harvey                           Health Protection Nurse (SWLHPU)
Simon Jefferies                         Dentist, Dental Advisor & LDC Secretary
Dr. Jill Leach                          Consultant Microbiologist & Infection Control Doctor
Sinead O’ Brien                         Director of Nursing, Primary Care & Integrated Governance
Dr. Barry Walsh                         Consultant in Communicable Disease Control (SWLHPU)
Judi Stallion                           Occupational Health Advisor


Acknowledgements
The following people co-wrote this guidance:
Nicola Sirin, Senior Infection Control Nurse, Kingston PCT
Carolyn Moore, Infection Control Nurse Specialist, Sutton & Merton PCT
Louise Harvey, Health Protection Nurse, South West London Health Protection Unit.




Issue Date: 10.01.08                                                                    Version No. 2.0
File: Prevention & management of Clostridium difficile Guideline                        Page 2 of 19
                                    Richmond and Twickenham Primary Care Trust



Record of Amendments
Date of Amendment               Version No                   Page No (s)         Paragraph No(s)



15.02.08                        1.0                          9                   9.1



22.02.08                        2.0                          8                   9




Issue Date: 10.01.08                                                                     Version No: 1.0
File: Prevention & management of Clostridium difficile Guideline                           Page 3 of 19
                                    Richmond and Twickenham Primary Care Trust



Contents                                                                                    Page
Consultation List and Acknowledgements                                                      2
Record of Amendments                                                                        3
Contents                                                                                    4

1.0            Introduction                                                                 5
1.1            Rationale                                                                    5
1.2            Scope and Disclaimer                                                         5
1.3            Principles                                                                   5

2.0            Background                                                                   5

3.0            Risk Factors                                                                 6

4.0            Clinical Signs and Symptoms                                                  6

5.0            Complications                                                                6

6.0            Diagnosis                                                                    6
6.1            Clearance And Repeat Specimens                                               7

7.0            Isolation                                                                    7

8.0            Patient Movement and Transfer                                                8

9.0            Clinical Management                                                          8
9.1            Prudent Antibiotic Prescribing                                               9

10.0           Hand Washing                                                                 9
10.1           Hand Hygiene And The Patient With Clostridium difficile Infection            9
10.2           Hand Hygiene And Community-Based HCWs                                        9

11.0           Personal Protective Equipment (PPE)                                          9

12.0           Routine Cleaning                                                             10
12.1           Terminal Cleaning                                                            10
12.2           Contaminated Bedding and Clothing In The Patient’s Own Home                  10

13.0           Monitoring Clostridium difficile infection                                   11
13.1           Sporadic cases                                                               11
13.2           Localised Cluster Of Cases                                                   11
13.3           Outbreaks                                                                    12
13.4           Outbreak Reporting                                                           12

14.0           Education and Training                                                       12

15.0           Surveillance for Clostridium difficile                                       12

16.0           Managers Responsibility                                                      13

17.0           Completion of Death Certificates                                             13

Appendices
Appendix 1          The Bristol Stool Form Scale                                            14
Appendix 2          Clostridium difficile care plan                                         15
Appendix 3          Level 1 Equality Impact Assessment                                      16

References                                                                                  18




Issue Date: 10.01.08                                                               Version No: 1.0
File: Prevention & management of Clostridium difficile Guideline                     Page 4 of 19
                                    Richmond and Twickenham Primary Care Trust



1.0       Introduction

This Clostridium difficile (C. difficile) prevention and management guideline was developed
collaboratively by infection control and health protection nurses in the South West London
sector. Adherence to this guidance will ensure compliance with Standards for Better Health core
standard C4(a); C21 and D12 (b) (DH, 2004).

1.1       Rationale
This guideline aims to support best practice on C. difficile prevention and management in
primary care and community healthcare settings, which is a requirement of all NHS Trusts under
The Health Act 2006 (DH, 2006).

1.2       Scope and Disclaimer

Richmond and Twickenham Primary Care Trust has prepared this guideline in good faith for use
by the Trust and its directly employed staff. This guideline forms part of the broader waste
management policy. See also:

         Infection Control Guidelines
         Health and Safety Policy
         Control of Substances Hazardous to Health (COSHH) Policy:

The statutory legal obligations of the PCT referred to within this guideline do not extend to the
activities of Primary Care Practitioners and their teams, who have a separate legal identity and
remain accountable as such. It is, however, recommended that where Primary Care
Practitioners develop policies for their organisation to follow that they refer to the Trust policy/
guideline for best practice guidance. In doing so it must be noted that the Trust cannot be held
responsible for the adoption and implementation of these local guidelines.

1.3       Principles

This guidance will be used to support best practice in infection prevention and control,
management of affected service users, and environmental cleanliness, to reduce the impact of
C. difficile infection and to restrict the numbers of service users affected.


2.0       Background
C. difficile has recently been the cause of major outbreaks of infection with numerous deaths
(Commission for Healthcare Audit and Inspection 2006; 2007). It is essential that in residential
healthcare settings, robust guidance is followed on suspicion of C. difficile in order to prevent
further spread and to minimize the impact of the infection on those affected. Robust
management to prevent secondary spread is essential. The main and most important aspects of
this guidance are:

         Effective patient management and care
         Isolation of patients who have symptoms of infection
         Hand washing with soap and water to decontaminate hands
         Maintaining a high standard of environmental cleanliness, with enhanced environmental
          cleaning in the presence of C. difficile infection, and terminal cleaning after outbreaks




Issue Date: 10.01.08                                                                  Version No: 1.0
File: Prevention & management of Clostridium difficile Guideline                        Page 5 of 19
                                     Richmond & Twickenham Primary Care Trust



         Appropriate use of personal protective equipment (PPE)
         Adherence to antibiotic prescribing policies


3.0       Risk Factors

         C. difficile infection is almost always associated with/ triggered by antibiotics prescribed
          to treat another condition or given prophylactically.
               o Duration of antibiotic therapy
               o Administration of multiple antibiotics or multiple courses
         Anti-ulcer medications
         Aged over 65 years
         Immunocompromised
         Serious underlying illness
         Non surgical gastrointestinal procedures
         Presence of a nasogastric tube
         Stay on ITU
         Duration of hospital stay


4.0       Clinical Signs and Symptoms

         asymptomatic
         offensive, explosive, watery diarrhoea
         abdominal pain
         fever
         nausea
         loss of appetite
         abdominal pain/ tenderness
         stool smell/ green appearance


5.0       Complications

         relapse diarrhoea
         dehydration
         pseudomembranous colitis
         toxic megacolon
         bowel perforation
         sepsis
         death


6.0       Diagnosis
Anecdotal evidence indicates that nurses are adept at diagnosing C. difficile infection in patients
by the ‘nose test’ due to the distinct smell of the stools. Laboratory diagnosis is by detection of
toxins A & B in faeces. Culture is not normally undertaken.

Loose stools from patients over 65 years are tested for C. difficile toxins (CDT) routinely as part
of the National Healthcare Associated Infection Surveillance programme. In all other patients,




Issue Date: 21.02.08                                                                   Version No:2.0
File: Clostridium difficile Management Guidelines                                       Page 6 of 19
                                     Richmond & Twickenham Primary Care Trust


specimens of diarrhoeal stool will only be tested for CDT if specifically requested. Stools from
children below 1 year are not normally tested for this organism.

         A stool sample should be taken and tested within 18 hours of onset of symptoms/
          admission of a symptomatic person
         Only one specimen needs to be sent to the laboratory for confirmation of diagnosis
         Specimens must be liquid and take the shape of the container. Formed stools will not
          be tested
         Repeat stool specimens are not needed whilst a person is symptomatic or when
          diarrhoea ceases.

CDT tests should be requested in patients with diarrhoea in the following situations:

         The patient is on or has been on antibiotics in the past 4 weeks.
         There is severe diarrhoea, fever, bloody stools or severe abdominal cramps.
         When previous cultures of stools were negative but symptoms persist.
         The patient developed diarrhoea whilst there was an existing case of C. difficile nearby.

6.1       Clearance and Repeat Specimens
Repeat stool specimens for CDT testing are not necessary within 1 month of diagnosis unless:

         Symptoms persist despite treatment - a further test may be undertaken after 4 weeks.
         Symptoms resolve and then recur which may suggest a relapse.


7.0       Isolation

         Patients with diarrhoea should be isolated unless their diarrhoea is known to have a
          non-infective cause.
         Patients with C. difficile diarrhoea must be isolated in a single room, preferably with an
          en-suite toilet and washing facilities. If an en-suite is not available a commode should
          be provided for their sole use.
         Patients with C. difficile diarrhoea should be given priority for isolation rooms, and
          where possible isolated on the ward where their diarrhoea commenced.
         Isolation room doors must remain closed and an isolation notice placed on the door.
         Cohort nursing or the opening of an isolation ward should be considered if the number
          of cases exceeds the number of single rooms.
         On entering the room, staff must wash hands with soap and water and don an apron
          and gloves.
         On leaving the room all staff must remove and dispose of apron and gloves into the
          clinical waste sack (orange sack) and wash hands using soap and water.
         A stool chart must be implemented and updated following every bowel action. The
          consistency of stools should be assessed and recorded using the Bristol Stool Form
          Scale (Appendix 1).
         Stool charts should record daily if a patient does not have their bowels open in order to
          prevent patients becoming constipated.
         If the patient is required to leave the room for diagnostic or treatment purposes the
          infection control team should be contacted for advice. It is not advisable to move the
          patient from the room whilst they have active diarrhoea, particularly if they are
          incontinent.




Issue Date: 21.02.08                                                                  Version No:2.0
File: Clostridium difficile Management Guidelines                                      Page 7 of 19
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         Patient transfers to other wards/ departments/ healthcare facilities must be kept to a
          minimum in order to prevent potential spread of infection.
         Patients with C. difficile infection can be removed from isolation after 48-72 hours
          without diarrhoea. There is no requirement to submit a faeces sample for testing.
         Patients with underlying bowel disorders who did not have semi-formed 'normal' stools
          prior to infection should be assessed by the ICT on an individual patient basis following
          two courses of antibiotic therapy. (Toxin tests are not used as a "test of cure".)
         Dispose of urine or faeces in the bedpan washer or macerator as rapidly as possible.
         All waste should be placed in an orange waste bag.
         All linen should be placed in a red alginate (dissolvable) bag before being placed in a
          red laundry bag.
         Equipment such as blood pressure monitors, commodes, temperature probe, etc.
          should be used only on that patient. If the equipment is taken for use elsewhere it
          should be effectively decontaminated - this would normally be with a chlorine-based
          disinfectant (see section 11.0) or via the sterile service department.
         Use normal crockery and cutlery and machine dishwash.
         Patients should be provided with an information leaflet on C. difficile.
         The patient’s GP must be notified of their C. difficile episode at discharge.


8.0       Patient Movement and Transfer

         If the patient requires transfer to another ward/ department/ healthcare facility, their C.
          difficile status must be declared in advance to allow appropriate arrangements to be
          made in the receiving department/ ward to prevent the spread of infection e.g.
          identification of side room accommodation.
         Infection control teams and staff at the receiving hospital should be informed both in
          writing and at the verbal handover.


9.0       Clinical Management
C. difficile infection must be treated as a condition in its own right and not as a complication
secondary to another condition. For symptomatic patients it is important to seek prescribing
advice from the Microbiologist/ Prescribing Team. In addition:

         STOP ANTIBIOTICS if possible.
         Anti-motility agents are contra-indicated in patients with antimicrobial associated
          diarrhoea
         For very ill patients/ when antibiotics cannot be stopped/ the diarrhoea does not settle
          within 48 hours of stopping antibiotics, treat with:
              o 1st choice Metronidazole 400mg tds orally for 7-10 days.
              o 2nd choice Vancomycin 125mg qds orally for 7-10 days.
         A stool chart must be used and updated after every bowel movement. The stools charts
          should also be used to record daily if a patient does not have their bowels open in order
          to prevent constipation. The Bristol Stool Form Scale (Appendix 1) should be used to
          assess stool consistency.
         Monitor fluid balance and correct dehydration caused by diarrhoea.
         Monitor signs of deterioration: rising CRP and WBC, pyrexia, falling albumin levels,
         Ensure kidney function is maintained to prevent renal failure




Issue Date: 21.02.08                                                                    Version No:2.0
File: Clostridium difficile Management Guidelines                                        Page 8 of 19
                                     Richmond & Twickenham Primary Care Trust



         Patients who experience prolonged C. difficile diarrhoea (>4 weeks) should be
          managed with advice from a consultant microbiologist.
         Assessment for colectomy – involve specialists (gastroenterologist/ surgeon) early
         Patients who develop diarrhoea following a period of being symptom-free may have
          been re-infected or relapsed. These patients must be isolated immediately and a faeces
          specimen sent for C. difficile toxin testing if more than one month since the previous
          toxin positive result.
         Centres of beds must be at least 3.6 metres apart in areas where patients with C.
          difficile infection are nursed together (cohorted).

9.1       Prudent Antibiotic Prescribing

         Avoid unnecessary use of antibiotics
         Avoid using broad spectrum antibiotics unless there is a good clinical need (especially
          extended spectrum cephalosporins and fluoroquinolones)
         Restrict prescription of IV antibiotics to a maximum of 48 hours in the first instance
         Use minimum duration and stop dates
         Monitor antibiotic usage and review antimicrobial medication daily.
         People who are asymptomatic/ colonised with C. difficile do not need to be treated with
          antibiotics.


10.0      Hand Washing                                   Refer to Trust hand hygiene guideline

Soap and water must be used for hand hygiene, not alcohol gel, which does not destroy C.
difficile spores.

All persons, including visitors, who have contact with the service user should wash their hands
thoroughly with soap and water
      before and after contact with the service user
      after contact with body fluids
      after contact with service user’s equipment and their immediate environment
      after removal of gloves and aprons

10.1      Hand Hygiene And The Patient With C. difficile Infection
All patients with C. difficile infection should be encouraged to wash their hands with soap and
water after using the toilet and before eating and drinking.

10.2      Hand Hygiene and Community-Based HCWs

         Soap and water must be used for hand hygiene, not alcohol gel as it does not destroy
          C. difficile spores.
         If liquid soap is not available in the person’s home, any liquid soap-based product can
          be used to wash hands. Bar soap should be used as a last resort.


11.0      Personal Protective Equipment (PPE)

         Always use disposable gloves and aprons for direct contact with the patient with C.
          difficile infection, their environment, and when handling body fluids.




Issue Date: 21.02.08                                                                     Version No:2.0
File: Clostridium difficile Management Guidelines                                         Page 9 of 19
                                     Richmond & Twickenham Primary Care Trust



         Visitors who do not assist in patient care and who have minimal patient contact do not
          need to wear gloves and an apron.
         Visitors assisting with patient care should wear gloves and an apron.
         All visitors should wash their hands with soap and water before they leave the room.
         Visitors should not eat or drink in the vicinity of the service user.


12.0      Routine Cleaning

For cleaning and disinfection in the presence of C. difficile infection, all surfaces and equipment
should be cleaned and disinfected using chlorine-based detergent (e.g. Actichlor plus/ Chlor-
clean). Refer to manufacturer’s guidance on preparation of these solutions.

NB Chlorine is an irritant to the skin and may damage soft furnishings and carpets. It should be
used with caution. Always refer to manufacturer’s instructions for equipment cleaning and
disinfection before applying chlorine based-products.

12.1      Terminal Cleaning

Following C. difficile infection, the patient environment must be thoroughly cleaned and
disinfected as described above, with careful attention to toilets, bathrooms and sluices,
commodes and bedpans.

         Chlorine-based detergent (e.g. Actichlor Plus/ Chlor-clean) should be used for cleaning
          and disinfection, as described above in section 12.0.
         Hydrogen peroxide vapour, ozone or steam may be used as additional disinfecting
          agents.

     Cleaning and disinfection should be carried out as follows:

               o    individual bed spaces/ side rooms when only one person was affected
               o    bays, when a number of C. difficile infected patients were nursed together
                    (cohorted)
               o    the entire ward where a large number of patients were affected and nursed
                    throughout the ward

The correct order of cleaning is as follows:

         Remove curtains and any linen. These must be laundered.
         Clean high surfaces first and work down to the floor.
         Therapy mattresses/beds must be labelled as contaminated and returned to the
          manufacturer for centralised decontamination.

Please refer to section 5 of The NHS Healthcare Cleaning Manual (NHS Estates, 2004) for
further guidance on terminal cleaning.

12.2      Contaminated Bedding/ Clothing In The Patient’s Own Home
     o    Where available, red alginate (dissolvable) bags should be used for removal of soiled
          bedding and clothing




Issue Date: 21.02.08                                                                 Version No:2.0
File: Clostridium difficile Management Guidelines                                     Page 10 of 19
                                     Richmond & Twickenham Primary Care Trust


     o    All clothing and bedding should be washed on the highest setting the fabric will tolerate,
          followed by tumble drying (where available).
     o    Contaminated items should be washed separately from other household laundry.
     o    Where larger items are contaminated e.g. mattresses, effective cleaning may not be
          possible and replacement may be necessary.


13.0      Monitoring Clostridium difficile Infection

The number and presentation of cases will influence the management of C. difficile infection.
Monitoring of C. difficile cases will result in initiation of 3 categories of management:

      I. Sporadic cases (hospital or community acquired)
     II. Localised cluster of cases (2 or more cases of hospital acquired C. difficile in a defined
         area i.e. ward per week where cross infection is suspected).These may occur
         sporadically without indicating an outbreak.
    III. Outbreak - site-specific C. difficile expected levels exceeded for 2 weeks or more than 3
         cases of hospital acquired infection per week for 2 consecutive weeks in a defined area.

13.1      Sporadic Cases

Implement guidance in sections 6.0 – 12.0. The Infection Control Lead will inform clinical
services if a potential cluster of hospital acquired C. difficile infection has been detected and will
review cases involved, including ward moves and exposure to other cases.

13.2      Localised Cluster of Cases
In addition to action taken for sporadic cases, the following measures should be implemented:

         Enhanced patient monitoring within the affected area by the infection control lead (ICL),
          with daily reporting of situation to Director for Infection Prevention and Control (DIPC)
          and Director of Nursing (DN).
         Control of staff deployment to other areas to ensure adequate staffing levels are
          present and to prevent transmission of C. difficile.
         Enhanced promotion of hand hygiene to raise awareness locally, with particular
          emphasis on the use of soap and water.
         Restriction of patient transfers and admissions to/ from affected area (ward/ bay) for 48
          hours to prevent 'seeding' of infection to other areas.
         Patients in the affected area who develop diarrhoea/ loose stools must have stool
          specimens sent for CDT testing.
         All patients in the affected area must have stool charts implemented.
         Typing of C. difficile isolates to be requested
         Staff working on the ward must change their uniforms on a daily basis. Sufficient
          supplies of uniforms must be available.
         Enhanced environmental cleaning should be implemented as described in section 12.0.
          The domestic supervisor should be included in discussions about enhanced cleaning to
          ensure continuity.




Issue Date: 21.02.08                                                                   Version No:2.0
File: Clostridium difficile Management Guidelines                                       Page 11 of 19
                                    Richmond and Twickenham Primary Care Trust



13.3      Outbreaks
The definition of an outbreak of C. difficile can be classified as diarrhoea with a positive toxin
assay (with or without a positive C. difficile culture) and/or endoscopic evidence, in two or more
related cases satisfying the above criteria over a defined period based on the date of onset of
the first case e.g. a second case in the same ward and week and/ or third case same ward and
month

The identification of more than three cases per week of hospital acquired infection, for two
consecutive weeks in a defined area will initiate specific actions by the ICL and the DIPC in
order to manage a potential outbreak of C. difficile.

In addition to guidance provided for localised clusters, the following additional measures should
be implemented:

     o    ICT and DIPC and DN should consider the need to form an outbreak committee. Chief
          Executive to be informed of decision.
     o    Potential outbreak to be reported to HPA and SHA by ICL with completion of Serious
          Untoward Incident (SUI) forms (Healthcare Associated SUI form to be submitted to HPA
          by ICT, trust SUI form to be submitted to SHA).
     o    Restriction on admissions to and transfer from all affected areas.
     o    Resolution of the cluster/outbreak will be confirmed by the ICL.
     o    Following confirmation, the affected area and all patient equipment will undergo a
          'terminal' clean as described in section 11.1.
     o    Patients may not be admitted to the ward until the 'terminal' clean is completed and the
          nurse in charge is happy with the standard of cleanliness.
     o    Audit of outbreak management to be undertaken by the ICL utilising the Department of
          Health Saving Lives High Impact Intervention no 6 - C. difficile. Results of the audit to
          be submitted to the Integrated Governance Committee.

13.4      Outbreak Reporting
All outbreaks of infection, suspected or confirmed must be reported. If, following root cause
analysis, it is proven not to be an outbreak, the SUI can be de-escalated, re-graded as a near
miss.

NB Positive results on the same patient within one month should be regarded as a single
episode; positive results on the same patient more than a month apart should be reported as
separate episodes.


14.0      Education and Training
The rollout of this guidance should be supported by specific training on C. difficile.


15.0      Surveillance for Clostridium difficile
Infections are broadly classified as "community acquired" i.e. confirmed within 72 hours of
admissions and "hospital acquired", confirmed after 72 hours of admission. Cases may arise
from the patients own "endogenous" flora or from cross infection - "exogenous". Infection control




Issue Date: 10.01.08                                                                 Version No: 1.0
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                                     Richmond & Twickenham Primary Care Trust


is the key to minimise the development of carriage. Antibiotic management is the way to reduce
disease.

The local microbiology departments monitor and record C. difficile results. Monitoring is
undertaken for national surveillance, which is reported to the Health Protection Agency. Where
numbers of cases exceed the expected norm for an area, the infection control team will initiate
an investigation. Unless it is reported to the infection control team, increased or unexpected
numbers of diarrhoea cases will not be obvious to infection control or microbiology. It is
therefore important that all staff are alert to increases in the number of patients with diarrhoea
and report these suspicions to the infection control team who will investigate.

         Action should be taken at >3 cases/ month and the full action plan implemented at 5-10
          cases a month.
         Outbreaks should be reported as SUIs.


16.0      Managers Responsibility
Managers are responsible for ensuring staff are aware of this policy and comply with all aspects
but with particular reference to:

     o    The timely taking of stool specimens
     o    Prompt isolation of patients
     o    Cleaning of the environment and equipment
     o    Antibiotic control
     o    Hand hygiene and adherence to standard principles of infection control

Managers are also responsible for ensuring staff have adequate supplies of equipment,
particularly consumables to ensure compliance with this policy.


17.0           Completion of Death Certificates
Deaths associated with C. difficile must be categorised as attributable or contributory and
adequately recorded on the death certificate.

         All deaths directly related to C. difficile as the primary cause of death should be
          identified on section 1a of the death certificate and/ or the patient record
         All deaths related to C. difficile because no other reasonable cause of death could be
          identified should be recorded at section 1b of the death certificate and/or the patient
          record




Issue Date: 21.02.08                                                                 Version No:2.0
File: Clostridium difficile Management Guidelines                                     Page 13 of 19
                                       Richmond and Twickenham Primary Care Trust

Appendix 1                              The Bristol Stool Form Scale

Type 1




Separate hard lumps like nuts (hard to pass)

Type 2




Sausage-shaped but lumpy

Type 3




Like a sausage but cracks on the surface

Type 4




Like a sausage or snake, smooth and soft

Type 5




Soft blobs with clear-cut edges (easily passed)

Type 6




Fluffy pieces with ragged edges, a mushy stool

Type 7




Watery, no solids pieces, entirely liquid
Reference: Heaton.K.W., Radvan J., Cripps H. et al (1992) Defecation frequency and timing and stool form in the general
population: a prospective study. GUT. 33: 818 - 824.




Issue Date: 10.01.08                                                                               Version No: 1.0
File: Prevention & management of Clostridium difficile Guideline                                    Page 14 of 19
                                                                                               Richmond and Twickenham Primary Care Trust

Appendix 2           Teddington Memorial Hospital Clostridium difficile care plan
Patient’s name_____________________________Ward________________________DOB______________GP__________________
Date   Potential problem    Goals                    Intervention                                                                                             Evaluation
       Transmission of      Prevention of            Isolate the patient
       infection to other   spread to other
                                                     Ensure dedicated toilet/ commode
       patients             service users
                                                     Careful attention to hand hygiene. Do not use alcohol gel.
                                                     Careful attention to cleaning and disinfection of patient environment and equipment
                                                     Use gloves and disposable aprons for direct contact with the patient/ their immediate
                                                     environment
                                                     Implement standard principles of infection control (universal precautions) at all times
       Misdiagnosis of      Correct diagnosis        Stool sample to lab for CDT within 18 hours of onset of symptoms/ admission to unit
       cause of                                      with diarrhoea
       symptoms
                            Prevention of            Monitor fluid balance and correct dehydration caused by diarrhoea
       Dehydration          dehydration
                                                     Use stool chart to record bowel movement/ absence of bowel movement

       Prolonged duration   Minimise duration        Use Bristol Stool Form Scale to assess stool consistency
       of symptoms          of symptoms
                                                     Monitor patient for other signs of deterioration
                                                     Administer antibiotic treatment as prescribed to treat C. difficile infection
                            Maintain                 Effective communication between
                            confidentiality,              all members of the multidisciplinary team
                            privacy and dignity           other healthcare institutions at transfer
                                                          ambulance service

                                                     Inform staff of patient’s C. difficile status on a need-to-know basis
                            Keep service user        Discuss C. difficile infection, treatment and care plan with patient and their relatives to
                            and their relatives      keep them informed
                            informed and
                                                     Provide leaflet on C. difficile
                            relieve anxiety
                                                     Discuss importance of and encourage hand hygiene
                                                     Advise visitors to wear gloves and an apron if involved in direct patient care and to
                                                     wash hands after removal



                                            Issue Date: 10.01.08                                                                            Version No: 1.0
                                            File: Prevention & management of Clostridium difficile Guideline                                 Page 15 of 19
                                       Richmond and Twickenham Primary Care Trust

Appendix 3 Level One Equality and Diversity Impact Assessment
Name of policy, procedure or           Prevention & management of Clostridium difficile Guideline
function assessed:
Date assessment started:               11.12.07

Aims, explanation of policy,           To provide clear guidance on Clostridium difficile infection, diagnosis,
procedure/ function/ service:          management and prevention of transmission.



1. Does the service disregard any particular needs of people in the following groups/or on account
of the following factors?
                                                       Yes                           No
Black and minority ethnic people                                                      
People with disabilities                                                              
Carers                                                                                
Age                                                                                   
Faith/ Religion                                                                       
Sexual orientation                                                                    
Gender                                                                                
Marital status                                                                        

What is the evidence? Has it arisen from other sources of feedback?

If any needs are disregarded, identify the action within the Action Plan in Section 9.


2. Is there evidence of direct /indirect discrimination/ lack of opportunity/ poor relationships against
any of the following groups , from your reading of the procedure or function/ service?
                                            No            Some         Strong evidence of discrimination
                                        evidence         evidence
Black and minority ethnic people            
People with disabilities                    
Carers                                      
Age                                         
Faith/ Religion                             
Sexual orientation                          
Gender                                      
Marital status                              
What is the evidence? Has it arisen from other sources of feedback?
N/a


3. Is the policy procedure or function proactive in meeting the needs of the following groups?
                                            No            Some        Strong evidence of discrimination
                                        evidence        evidence
Black and minority ethnic people
People with disabilities
Carers
Age
Faith/ Religion
Sexual orientation
Gender
Marital status
State how this policy is proactive by giving examples.

N/a




Issue Date: 10.01.08                                                                      Version No: 1.0
File: Prevention & management of Clostridium difficile Guideline                           Page 16 of 19
                                         Richmond & Twickenham Primary Care Trust

4. Are their sources of feedback that indicate examples of discrimination? Yes/No
                                           No            Some          Strong evidence of discrimination
                                        evidence       evidence
Black and minority ethnic people            
People with disabilities                    
Carers                                      
Age                                         
Faith/ Religion                             
Sexual orientation                          
Gender                                      
Marital status                              
4 a. Name the sources. What have been your findings?
Please give reasons/ examples, sources of feedback and whether the discrimination is direct/ indirect
N/a

4b. Which of the following sources of evidence been scrutinised?
                                                     Yes                                         No
Demographic profiles                                                                
Internal research reports
Staff/ patient, public surveys
Benchmarking reports
Ombudsman cases
Equality monitoring reports
Research reports (internal/ external
Media reports
Consultation findings
Employment tribunal cases
Complaints, grievances, disciplinary
cases
Other, please specify



5.Is the policy/procedure/function/service likely to          5a If it has an adverse impact. Can you justify this
have an adverse impact overall?                               impact? e.g., business case, service need, client
No                                                            need. N/a
6. Can you justify the adverse impact overall?                6a If you cannot justify it how do you intend to
N/a                                                           deal with it? N/a
7.Is the intention of the policy/procedure                    7a Is it sufficiently flexible to meet the needs of a
function/service rigid or flexible? Flexible                  diverse user/staff group? Yes
8 Are there reasons for carrying out a more                   8a Is there evidence of discrimination? No
detailed assessment? I.e. level 2 or
3 as appropriate? No
8b Is there high negative impact on                           8c If yes
groups/equalities aspects identified in previous
questions? No

Action plan:
Issue              Action               Lead person       Timescale            Resource          Comments
                   required
Issue              Action               Lead person       Timescale            Resource          Comments
                   required
Issue              Action               Lead person       Timescale            Resource          Comments
                   required
Issue              Action               Lead person       Timescale            Resource          Comments
                   required

Report compiled by Shona Ross, Infection Control Lead
Date 11.12.07



Issue Date: 21.02.08                                                                         Version No:2.0
File: Clostridium difficile Management Guidelines                                             Page 17 of 19
                                         Richmond & Twickenham Primary Care Trust

References, sources and further reading
Commission for Healthcare Audit and Inspection (2007) Investigation into outbreaks of Clostridium
difficile at Maidstone and Tunbridge Wells NHS Trust [online] [15.10.07]
http://www.healthcarecommission.org.uk/_db/_documents/Maidstone_and_Tunbridge_Wells_investig
ation_report_Oct_2007.pdf

Commission for Healthcare Audit and Inspection (2007) The management of Clostridium difficile.
London. Commission for Healthcare Audit and Inspection.

Commission for Healthcare Audit and Inspection (2006) Investigation into outbreaks of Clostridium
difficile at Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust. London. Commission for
Healthcare Audit and Inspection

Department of Health (2008) The Health Act 2006 Code of Practice for the Prevention and Control of
Health Care Associated Infections (revised 2008). London. Department of Health.

Department of Health (2007) High Impact Intervention No 7: care bundle to reduce the risk from
Clostridium difficile. London. Department of Health.

Department of Health (2007) Changes to the mandatory healthcare associated infection surveillance
                                                                                     th
system for Clostridium difficile associated diarrhoea (letter from CMO & CNO dated 11 April 2007).
London. Department of Health.

Department of Health (2007) A simple guide to C. difficile. London. Department of Health.

Department of Health (2007) Essential Steps to Safe, Clean Care. London. Department Of Health.

Department of Health (2006) The Health Act 2006 Code of Practice for the Prevention and Control of
Health Care Associated Infections. London. Department of Health.

Department of Health (2006) Essential Steps to Safe, Clean Care. London. Department Of Health.

Department of Health (2006) Saving Lives: a delivery programme to reduce Healthcare Associated
Infection including MRSA. High Impact Intervention No6: Reducing the risk of infection from and the
presence of Clostridium difficile [20.11.07] [online]
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh
_4135387.pdf

Department of Health (2006) Healthcare associated infections, in particular infection caused by
Clostridium difficile (letter to all Trust, PCT and SHA Chief Executives). London. Department of
Health.

Department of Health (2005) Infection caused by Clostridium difficile (letter from CMO & CNO dated
  st
21 December 2005). London. Department of Health.

Department of Health (2005) Surveillance of Clostridium difficile associated disease (CDAD) [online]
[25.11.07]
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4
118344

Department of Health (2004) Standards for Better Health. London. The Stationery Office.

Department of Health/ Public Health Laboratory Service (2004) Clostridium difficile infection
prevention and management. A report by a Department of Health/ Public health laboratory service
joint working group. London. Public Health Laboratory Service.

Hawker J., Begg N., Blair I., Reintjes R., Weinberg J. (2001) Communicable Disease Control
Handbook. Oxford. Blackwell Science.

Health Protection Agency (2007) HPA Regional Microbiology Network. A good practice guide to
control Clostridium difficile. London. Health Protection Agency.

Issue Date: 21.02.08                                                                Version No:2.0
File: Clostridium difficile Management Guidelines                                    Page 18 of 19
                                         Richmond & Twickenham Primary Care Trust

Health Protection Agency (2007) Clostridium difficile [online] [25.11.07]
http://www.hpa.org.uk/infections/topics_az/clostridium_difficile/default.htm
Health Protection Agency (2006) Clostridium difficile: Findings and recommendations from a review of
the epidemiology and a survey of Directors of Infection Prevention and Control in England [online]
[25.11.07] http://www.hpa.org.uk/infections/topicsaz/clostridiumdifficile/publications.htm

Health Protection Agency and Healthcare Commission (2005) Interim findings from a national survey
of NHS acute trusts in England: A joint report by the. London. Healthcare Commission and the Health
Protection Agency.

Heaton.K.W., Radvan J., Cripps H. et al (1992) Defecation frequency and timing and stool form in the
general population: a prospective study. GUT. 33: 818 - 824.
                 th
Hoffman, P (7 December 2007) (personal communication).

Infection Control Services Ltd (2007) Control and Management of Clostridium difficile. [online]
[15.10.07] http://www.infectioncontrolservices.co.uk/clostridium_difficile.htm

Kingston Hospital (2007) Clostridium difficile guideline (unpublished).

National Clostridium difficile Standards Group (2003) National Clostridium difficile Standards group
report to Department of Health [online] [25.11.07]
http://www.his.org.uk/_db/_documents/FINAL_C_diff_report.pdf

NHS Estates (2002) Infection Control in the Built Environment. London. The Stationery Office.

NHS Estates (2004) The NHS Healthcare Cleaning Manual Section 5 Cleaning Method Statements
[online] [06.12.07]
http://patientexperience.nhsestates.gov.uk/clean_hospitals/ch_downloads/cleaning_manual/cleaning_
manual_section_5.pdf

NHS London (2007) Reporting of Serious Untoward Incidents related to HCAI (letter to London PCT
Chief Executives dated 21st November 2007). London. London Strategic Health Authority.

National Patient Safety Agency (2007) Safer Practice Notice 15: Colour coding hospital cleaning
materials and equipment [online] [11.01.07]
http://www.npsa.nhs.uk/site/media/documents/2140_0429colourcodingsp1D2F4.pdf

Office for National Statistics’ Death Certification Advisory Group (2005) Guidance for doctors
certifying cause of death [online] [29.10.07]
http://www.gro.gov.uk/Images/certifiers_guidance_v2_tcm69-21289.pdf

St. Georges Hospital (2006) Clostridium difficile guidance (unpublished).

Shropshire county & Telford & Wrekin Primary Care Trust (2007) Infection Control Policy
(unpublished).




Issue Date: 21.02.08                                                                Version No:2.0
File: Clostridium difficile Management Guidelines                                    Page 19 of 19

				
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