The Care Bundle for Minimising Cross Transmission of Clostridium difficile

1
The Care Bundle for Minimising Cross Transmission
of Clostridium difficile

• How to use it to reduce the risk of CDAD in your
  ward

2
Clostridium difficile - What is it?

• Gram-positive (absorbs crystal violet stain)
• Anaerobic (does not require oxygen to survive)
• Bacillus (rod shaped)
• Spore forming(can survive in the environment for
  months)

3
Why do we need a care bundle for C. difficile ?
4
Incidence is rising. Incidence in Scotland
1994-2005Based on voluntary laboratory reporting
HPS Weekly Report, 7 March 2006
5
Over 6000 cases identified in the first year of
full surveillance in Scotland
6
High profile outbreaks showing that best practice
is not universal
7
Pseudomembraneous colitis is a severe
life-threatening disease
8
How do you know you have a case of Clostridium
difficile?

• A case of CDAD is someone in whose stool C.
  difficile toxin has been identified at the same
  time as they have experienced diarrhoea not
  attributable to any other cause, or from cases of
  whose stool C. difficile has been cultured at the
  same time as they have been diagnosed with PMC
  (pseudomembranous colitis).
• Protocol for the Scottish Surveillance Programme
  for Clostridium difficile Associated Disease V2
  2007

9
How do we ensure that best practice is always
done?
10
Quality Improvement

• There are a range of tools that can be used to
  improve the quality of care and patient safety
• The use of care bundles are one of these tools
  that has shown most promise
• Bundles become successful when they are deployed
  by using rapid PDSA testing cycles, starting with
  one patient, one doctor and one nurse.

11
A bundle is

• A structured way of improving the processes of
  care and patient outcomes
• A small, straightforward set of practices -
  generally three to five - that, when performed
  collectively, reliably and continuously, have
  been proven to improve patient outcomes. 
• For more information see the IHI website at
  http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/WhatIsaBundle.htm

12
What makes bundles effective at improving
practice?

• The bundles are based on the best available
  evidence
• All or nothing assessment
• Each bundle criteria is critical to achieving the
  bundle and improving care, so the bundle is
  scored only if all the criteria are achieved.
• The bundle is measured at the same time in the
  same place so that any changes in the results
  will reflect any changes in practice

13
What is in the HPS bundle pack?

• A statement of commitment for the clinical team
  to sign
• A standard operating procedure for the bundle
  including the bundle criteria
• The data collection sheet
• A cause and effect chart

14
The CDAD bundle minimising cross transmission
from patients with CDAD

• (It is not aimed at supporting primary
• prevention of CDAD cases or aimed at
• specifically supporting outbreaks although
• may be useful at these times)

15
The bundle is based on these important goals

• Isolate affected patients
• Stopping inappropriate antibiotics
• Effective infection control measures

16
The bundle criteria are

• Isolating CDAD patients in a single room with
  either en suite facilities or an allocated
  commode, until they are least 48 hrs symptom free
• Reviewing antibiotic regimes and stopping
  inappropriate antibiotics
• Checking all HCWs remove PPE (gloves and aprons)
  after each CDAD patient care activity
• Checking that the CDAD patients immediate
  environment has been cleaned today with a
  chlorine based solution
• Ensuring HCWs perform hand hygiene with liquid
  soap and water after leaving a CDAD patients room

17
Why have we picked these bundle criteria?
18
The bundle criteria

• The bundle was created from the best available
  current evidence on the key measures that
  minimise cross transmission from patients with
  CDAD
• The bundle may change as new evidence emerges
  over time

19
Information
HPS Infection Control Team Literature search and
critique strategy
http//www.hps.scot.nhs.uk/index.aspx
20
It is most important to emphasise that effective
CDAD prevention and management involves other
practices, these must not be neglected whilst
concentrating on the bundle criteria.
21
A cause and effect chart was prepared from the
literature reviews which identifies all the key
criteria required to prevent cross-transmission.
(Shown in the next slide).
22
See the web pages for a copy of this.
23
How you used the bundle and incorporate it into
your daily or weekly regimens is up to you and
your clinical team. A sample data collection
sheet is shown overleaf.
24
(No Transcript)
25
Before you start a bundle

• You have to realise that quality improvement must
  be continuous
• This is not a short term commitment quality
  improvement needs to be embedded into your
  systems to become part of what you do every day

26
The next few slides describe the 7 steps in
successful bundle implementation
27
Step 1 - CommitmentThe first step is for the
team leader to get everyone to commit to doing
the bundle to improve patient safety.
Remember Patient safety is for life not just
for Christmas!
28
Step 2 - Understand there will be consequences

• The team must consider that they will find out
  things they did not want to know, e.g. your team
  is not perfect!
• Consider how you will deal with this before you
  start
• Commit to feedback being for improvement and not
  judgement
• Acknowledge that where you are, is not where you
  want to be, and this process will help you
  improve
• Commit to not shooting the messenger, i.e. the
  one collecting the data!
• Commit to a no blame culture
• Remember you are doing this for optimal patient
  safety and to show the quality of your care not
  to damage your care team

29
Step 3 - Work out the process that fits in with
your systems of working

• How often do you want to measure compliance (at
  least once a week)?
• Who will collect the data?
• When will they collect the data?
• Where will they put the completed sheets?
• Where will you display your results?
• What will you do with the results how will you
  act on them?
• Is everyone agreed on the process?

The data must be collected on the same date and
at the same time!
30
Step 4 Start small

• Remember the PDSA methodology
• One patient, one nurse, one doctor, one day
• The next time three patients
• The next time five patients
• The next time all
• Dont expect to get it right first time

31
Step - 5 Ready, Steady, Go

• When you are all agreed it works on five, get
  ready to implement it ward wide
• Pick a start date
• Make sure everyone knows
• Have the bundle data collection forms ready
• BEGIN

32
Step 6 Continuously assess progress
X reduction in acquired cases of CDAD (decided
locally)
There will be 100 compliance with
processes There will be reduced numbers of CDAD
cases
The incidence of CDAD on our ward will decrease
over time.
The next slide has some considerations to help
improve processes
33
Process Improvement
Any redundant steps
Can you stop it? e.g. antibiotics
Make it easier
Make it better
34
Step 7 If its going well and you have improved
processes and minimised cross transmission from
patients with CDAD try another bundle
If you find out anything that would help others
contact HPS icqi_at_hps.scot.nhs.uk
35
Well done for committing to improving patient
safety in your ward