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					                                                                    AGENDA ITEM NO: 8

     LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST

                            BOARD OF DIRECTORS

                                  27 JUNE 2007

        PREVENTING HEALTHCARE ASSOCIATED INFECTION –
                     PROGRESS UPDATE

1.     INTRODUCTION

       There is increasing national focus on reducing the incidence and impact of
       healthcare associated infection. This paper provides overview and update on
       the actions to reduce healthcare associated infection and details the
       background and impact of Clostridium difficile (C. diff.).

2.     REDUCING HEALTHCARE ASSOCIATED INFECTION

       In recognition of the “whole system” approach needed to tackle and reduce
       healthcare associated infection the Trust established an infection prevention
       action plan and work programme in 2005. The action plan identifies the priority
       areas for action, lead responsibilities and timescales for change. Progress is
       reviewed quarterly and the plan is updated in the light of new developments
       and national policy. Priorities for 2007/8 include

       •   Standardising intravenous line management
       •   Expanding MRSA screening programmes (currently high risk patients in
           Orthopaedics, Surgery, Critical Care, Neurosurgery, Renal Medicine and
           Plastic Surgery are screened)
       •   Increasing the provision of isolation facilities
       •   Reviewing cleaning schedules

       The updated action plan incorporates measures geared towards tackling MRSA
       and clostridium difficile and will be considered at the next meeting of the Risk
       Management Committee.

       Over the course of 2006-2007 there was a reduction in the number of reported
       MRSA bacteraemias as compared with the previous year. Whilst this reduction
       demonstrates that significant progress is being made, the trajectory of 34 was
       not achieved (a total of 37 were reported).

       The trajectory for 2007/8 has been further reduced in line with the national
       commitment to reduce MRSA bacteraemias by 50% and is now set at 22. This
       is a very challenging target. Trends can vary within year and current
       performance is in excess of this. The inclusion of data for contaminated
       specimens and patients transferred or admitted to the Trust who are found to
       have a bacteraemia on arrival has a significant impact on reported
                                          2

     performance, particularly when the trajectory is so low (currently only 2 per
     month).
     All reported bacteraemias are subject to root cause analysis (a learning tool
     utilised to assist the identification of causational factors). Monthly meetings are
     held with the PCT and Infection Control Team to review the outcomes of root
     cause analysis, this intelligence is then fed back to clinical teams and utilised to
     inform future policy and practice. Progress is monitored at Infection Control
     and Clinical Governance Committees. Performance reviewed and monitored as
     part of the Trust performance management arrangements.

     The next section details the background and impact of clostridium difficile.

3.   CLOSTRIDIUM DIFFICILE

     Clostridium difficile is a gram positive, spore forming bacillus, which has been
     increasingly recognised as an important cause of diarrhoea, particularly in older
     patients. The organism can cause disease under certain conditions – this
     varies from mild, almost inconsequential symptoms, to very severe symptoms
     that in the minority of cases can be life threatening. The mortality is about
     1.5 % of all hospitalised cases of C. diff. diarrhoea.

     Over the last decade diarrhoea due to C. diff. has become a growing concern in
     hospitalised patients. In recognition of this fact, mandatory surveillance of C.
     diff. associated disease in England and Wales began in January 2004. This
     data is collected by Trusts in addition to data about numbers of MRSA
     bacteraemia (blood stream infection).

     The disease process by which C. diff. causes symptoms relies on the organism
     being present in the gut and then proliferating (multiplying) when the other
     bowel flora are affected by antibiotics (in the healthy gut, this normal flora
     protects against C. Diff). When C. diff. proliferates it produces toxins and
     directly damages the bowel wall. In its most severe clinical manifestation, the
     damaged large bowel perforates placing the recipients life at risk.

     The clinical picture of C. diff. varies widely, between someone who has a single
     episode of loose stools, which without any specific treatment returns to normal,
     and a person who is at the other end of the spectrum, who has a much more
     severe form of the infection with symptoms as described above; fortunately the
     latter cases are in the minority.

     The diagnosis is made by a test carried out on a stool specimen in the
     microbiology laboratory and relies on the detection of C. diff. toxin. The
     bacterium is present in the gut of about 3 % of healthy adults and two thirds of
     infants, but very rarely causes problems, as it is kept in check by the normal
     bacterial flora. Only when the normal flora is decreased by antibiotics, is this
     balance disturbed and C. diff. then has the potential to cause problems, as
     described above.

     A key component of the organism is its ability to form spores. These are shed
     into the environment when a symptomatic patient has diarrhoea and have the
                                                        3

     ability to survive for prolonged periods (they are resistant to air, drying and
     heat).


4.   EPIDEMIOLOGY

     Since data has been collected about cases of C. diff., there has been a year on
     year rise in the national total. The national rise over 2006 was 8%, with 55,681
     cases in total. Over the preceding year (2004-2005) the increase was 17 %.
     There are no national targets for reducing C. diff. A recent (April 2007)
     Department of Health letter, from the CMO and Chief Nurse, instructs that a
     target for reduction should be agreed locally. Discussions with Central
     Lancashire PCT are in progress and proposals for a local target will take into
     consideration current performance.

     There are two components to surveillance of C. diff. infection: local data
     collection, which has been in place for inpatients at Royal Preston and Chorley
     Hospitals for 10 years, and the Trust contribution to mandatory national
     surveillance. Rates of C. diff. (expressed as cases per 1000 bed days) vary
     widely between different Trusts, in some cases reflecting the nature of the
     patient population. Tables 1 and 2 illustrate the rise in the national rates
     reported and the Trust’s performance.

     Table 1 – Presents North West C. diff. Surveillance Data


           C. difficile mandatory surveillance, > 65 yrs
           North West
           Annual figures & rates
                             Numbers   Annual Rate per 1,000 bed days for patients 65 yrs & over


                      8500                                                                         5
                      7500                                                                         4.5
                                                                                                   4
                      6500
                                                                                                   3.5
                      5500
            Numbers




                                                                                                   3
                                                                                                         Rate




                      4500                                                                         2.5
                      3500                                                                         2
                                                                                                   1.5
                      2500
                                                                                                   1
                      1500                                                                         0.5
                      500                                                                          0
                               2004                    2005                      2006
                                                                                                   4




                                                Table 2 – Presents C. diff. Rates by Trust (Jan 2006 – Dec 2006)
     Rate/1000 bed days over 65 years of age




                                                                           NW trusts C. diff rates 2006

                                                 3.50
                                                 3.00
                                                 2.50
                                                 2.00
                                                 1.50
                                                 1.00
                                                 0.50
                                                 0.00

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                                                It is important to note that national data has to date recorded C.diff rates for
                                                patients aged 65 or over per 1000 occupied bed days. In April 2007 national
                                                data has been adjusted to include all C. diff rates. It is anticipated that future
                                                performance will be assessed on this measure. This explains the variance in
                                                rates as reported in table 2 (1.9%) and 3 (1.2%).

5.                                              THE LOCAL PICTURE

                                                In January to April 2007 there was an increase in C. diff. cases, compared to
                                                the same period in 2006. Three ward areas have experienced higher numbers
                                                of cases than usual during this time and have been subject to an intense
                                                response in terms of daily meetings as well as outbreak review meetings. The
                                                agreed measures were implemented and have been successful at containing
                                                the situation. Antibiotic prescribing was identified as a common feature of this
                                                outbreak and led to rationalisation of prescribing within respiratory and
                                                orthopaedic settings. A detailed report of the circumstances surrounding this
                                                increase is in preparation.

                                                A proportion of reported cases have been due to the 027 strain of C. diff. (the
                                                typing data has not been gathered for all cases, so gives only a snapshot).
                                                Evidence is emerging from a number of sources that the 027 strain can cause
                                                                                                             5




                                     outbreaks and is also associated with more severe disease than other strains.
                                     This strain was associated with the outbreak at Stoke Mandeville Hospital,
                                     which lasted from 2003 to 2005, leading to a major public inquiry.

                                     Table 3 – Presents C. diff rates for all patients 65 or over


                                                     Clostridium difficile reports at LTHTr per 1000 bed days
                                                                         April 06 - March 07

                                       2
     Number of C.difficile reports




                                     1.8
                                     1.6
                                     1.4
                                     1.2
                                       1
                                     0.8
                                     0.6
                                     0.4
                                     0.2
                                       0
                                                     6         6     6        6    6    6        6        6        6        7    7     7
                                                -0          -0    -0     l- 0   -0   -0       -0       -0       -0       -0   -0   r-0
                                            r             ay J un      Ju Aug Sep           ct      ov        ec       an Feb Ma
                                         Ap              M                                O        N        D        J




5.                                   REDUCING THE INCIDENCE OF C. DIFF.

                                     Actions to prevent and control C.diff. have been disseminated across the Trust.
                                     These include:

                                     •     Rationalising and monitoring antibiotic prescribing.

                                     •     Promoting hand hygiene and the appreciation that hand washing is needed.
                                           Alcohol gel is not effective in combating C. diff.

                                     •     Environmental and equipment cleaning.

                                     •     Investigating and isolating symptomatic patients.

                                     •     Providing information for patients and visitors.

                                     Guidance and surveillance information about both MRSA bacteraemia and
                                     cases of C. diff. is disseminated to directorates via the Infection Control
                                     Committee and Clinical Governance Sub-Committee, Trust Management Team
                                     and the Nursing & Midwifery Advisory Group.
                                            6


6.      RECOMMENDATION

        The Board of Directors is asked to note the actions to tackle healthcare
        associated infection.




SUE REED                                  AMANDA BARNES
NURSING DIRECTOR                          DIRECTOR OF INFECTION AND
                                          PREVENTION AND CONTROL

JOHN CHEESBROUGH                          ANDREW CHALMERS
CONSULTANT MICROBIOLOGIST                 NURSE CONSULTANT, INFECTION
                                          CONTROL




References:

     1. Review: pathogenesis and treatment of Clostridium difficile infection Tanna &
        Welsby, Postgraduate medical journal 2005;81: 367-369


     2. Clostridium difficile infection: Prevention and Management. A report by a
        Department of Health/PHLS joint working group. BAPS health publications unit,
        Heywood, Manchester 1994 (also available via HPA website, www.hpa.org.uk)

     3. HPA slides available from: <http://www.hpa.org.uk/northwest/default.htm>

				
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Description: Clostridium difficile was first recognised as the cause of some