How to use it to reduce the risk of CDAD in your ward The Care Bundle for Minimising Cross Transmission of Clostridium difficile How to use it to reduce the risk of CDAD in your ward

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)

Why do we need a care bundle for C. difficile ?

Incidence is rising…. Incidence in Scotland 1994-2005 Based on voluntary laboratory reporting HPS Weekly Report, 7 March 2006

Over 6000 cases identified in the first year of full surveillance in Scotland

High profile outbreaks showing that best practice is not universal

Pseudomembraneous colitis is a severe life-threatening disease

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

How do we ensure that best practice is always done?

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.

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/IntensiveCare/ImprovementStories/WhatIsaBundle.htm

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

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

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)

The bundle is based on these important goals: Isolate affected patients; Stopping inappropriate antibiotics; Effective infection control measures

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 patient’s 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 patient’s room

Why have we picked these bundle criteria?

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

HPS Infection Control Team Literature search and critique strategy Information… HPS Infection Control Team Literature search and critique strategy http://www.hps.scot.nhs.uk/index.aspx

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.

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).

See the web pages for a copy of this.

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.

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

The next few slides describe the 7 steps in successful bundle implementation

Patient safety is for life – Step 1 - Commitment The 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!

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

The data must be collected on the same date and at the same time! 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!

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 Don’t expect to get it right first time

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

Step 6 Continuously assess progress What are we trying to accomplish? How will we know that change is improvement? What changes can we make that will result in improvement? Act Plan Study Do 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

Can you stop it? e.g. antibiotics Any redundant steps Can you stop it? e.g. antibiotics Process Improvement Make it easier Make it better

Step 7 – If it’s 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@hps.scot.nhs.uk

Well done for committing to improving patient safety in your ward