Using Root Cause Analysis to tackle C. difficile infections Audio Conference Call October 13, Dr. Tony Maggs Director of Infection Prevention & Control Torbay Hospital South Devon Health Care, NHS Foundation Trust

Collaborative Updates Regional Workshops – Register Now!  November 8 th 8:30am-12:30pm at St. Luke’s Hospital, New Bedford, MA  November 9 th 8:30am-12:30pm at Western Massachusetts Hospital, Westfield, MA  November 10th 1-5pm at Metro West Medical Center, Leonard Morse Campus, Natick MA Antibiotic stewardship workgroup  10 hospitals enrolled  First call November 5, 1pm  Space still available Team leader feedback  Our own PDSA: share your feedback and requests

Using Root Cause Analysis to tackle C difficile infections…. Dr Tony Maggs, Director of Infection Prevention & Control - on behalf of the Infection Control Team and all the staff of Torbay Hospital 13 th October 2010: Massachussets CDI Prevention Learning Collaborative

South Devon Healthcare NHS Foundation Trust 3,773 staff (= 3,140 FTE) Torbay District General hospital Local population of around 280, % over 65 (national average 19%) 450 beds (around 15% side rooms; ≈$150M backlog maintenance) Average length of stay 3.6 days (down from 4.7 in 2004) In top 3 nationally for day case rates Bed occupancy >85% ‘Managed through culture’

0.68 / 1,000 bd 0.20 / 1,000 bd (70% reduction)

How did we improve? Root Cause Analysis Environmental cleaning routine use of hypochlorite; greater frequency; dedicated cloths per bed space Antibiotic prescribing better guidelines; frequent audit and feedback; more education for junior docs Hand hygiene when and how (SPI 2)

Started RCA process

Root cause analysis Started for hospital acquired cases in autumn 2007 Investigational team must include; a medical rep (consultant or junior doctor) a nursing rep an infection control rep - plus others as appropriate Aimed to be as flexible as possible during RCA no blame establish timeline: “what do you want to celebrate and share?” “what do you wish had never happened – and how would you avoid it next time around?”

Root cause analysis Early learning - often a multitude of things going wrong - ‘shame / embarrassment‘ is a powerful driver for change! - talking about problems / sharing learning at clinical meetings → getting C difficile on clinical agenda Principal benefits More understanding about risk (“trigger questions”) C difficile is not an inevitable part of modern healthcare – it is an avoidable event

Root cause analysis – clean safe care tried the new tool stifled discussion medics switched off ‘closed’ analysis -> formalise our processes lay out RCA process make local ownership more consistent work up full list of trigger questions incorporate ‘good bits’ into local tool better control of action plans } Very detailed / data driven (eg policy revision dates & compliance audits)

Root cause analysis Hospital acquired C difficile infection Root Cause Analysis (lead by matron) Action Plan (signed off by associate director of nursing and clinical director) Healthcare Associated Infection Group (monitored by trust operational group charged with implementing annual Healthcare Associated Infection Action Plan) Serious Adverse Event Group (for information) (10 days) Review of standard practices

Speed is key…… How quickly was diarrhoea flagged up? How quickly was the patient isolated? How quickly was the area cleaned? How quickly was the sample collected? How quickly was empirical treatment started? How quickly was a positive test responded to? How quickly was any failure to improve reacted to? How quickly were other treatments reviewed? How quickly did the lab report the result?

Root cause analysis – selected trigger questions (1) Was D&V assessment undertaken and documented within the medical notes on admission? Has the patient had C difficile within the last 12 months? Was this reflected in the medical notes? Was the patient weighed on admission? Evidence of malnutrition? If the patient started antibiotics, was this in keeping with trust guidelines? Did the potential benefit of antibiotic treatment outweigh the potential risks?

Root cause analysis – selected trigger questions (2) When did the patient commence with diarrhoea and was it documented in the medical records? Is there an assessment of diarrhoea severity in the medical notes (e.g. frequency, stool consistency, systemic upset including WCC, CRP etc)? Was empirical treatment for C difficile given? If not already happened, following the positive lab report, how quickly was C difficile treatment commenced? How were other clinical teams on the ward made aware of this new diagnosis?

Root cause analysis – selected trigger questions (3) Was the side room cleaned twice daily with hypochlorite solution and was this recorded? What method of hand hygiene was promoted? How? Were doses of treatment ever missed, eg through patient refusal or medical condition? Is this reflected in the medical notes?

South Devon Healthcare NHS Foundation Trust Internal target of zero clusters of C difficile National target in 2009/10 of <= 70 cases Actual number 27 cases (8 possible clusters - doubtful) → better care for patients; better life for staff In nearly half of all months, we only have one hospital acquired C difficile case → everything becomes more manageable