C. Difficile: The Scarborough experience

Infection prevention and control (IP&C) at Scarborough and North East Yorkshire Healthcare NHS Trust is showing impressive results following a challenging three years.

The Trust’s Clostridium Difficile rate per 1,000 bed days had not decreased since 2007 and despite always being just below the set trajectory, most other trusts had halved their incidence.

In spring 2009 the trust experienced an outbreak of the 027 strain of Clostridium difficile with a cluster of cases in April, May and June affecting one ward.

WHAT IS C. DIFFICILE?
Clostridium difficile is a spore forming bacteria that three per cent of healthy people and ten to 20 per cent of hospitalised people carry in their gut. It is normally kept in check by the bowels friendly bacteria (flora). Infection ranges from mild to severe diarrhoea to, more unusually, severe inflammation of the bowel (known as pseudomembranous colitis).

The 027 ribotype is a virulent strain which produces more toxin and has a higher morbidity, relapse and mortality rate. It resists standard cleaning and has a greater environmental contamination rate than other strains.

People who have been treated with broad spectrum antibiotics (those that affect a wide range of bacteria), people with serious underlying illnesses and the elderly are at greatest risk – over 80 per cent of Clostridium difficile infections reported are in people aged over 65 years.

C. Difficile infection may cause outbreaks in communal settings (for example hospital and care facilities) spreading directly from patient to patient or being acquired from the environment, contaminated equipment or via HCW hands.

DEALING WITH AN OUTBREAK
Following standard outbreak control measures in April to June 2009 – including ward closure, reviewing antimicrobial prescribing and decontamination – the outbreak was declared closed.

In December 2009 a rise in incidence was detected and ribotyping of strains proved that the trust was once again affected by the 027 strain and it had affected several wards.

An executive led outbreak committee was established and an action plan was produced.

However, following a number of infection control measures and changes in practice the situation has improved dramatically with the number of cases of C. Difficile within the trust reduced by 30 per cent, meaning that the trust attributed cases was 20 cases below its trajectory.

ABOUT THE TRUST
The Trust which runs two hospitals – Scarborough General Hospital and Bridlington District Hospital – provides a range of acute hospital services for around 240,000 people living in and around Scarborough, Bridlington, Whitby and Ryedale.  

The diverse area also covers communities in the market towns of Malton, Norton, Driffield, Pickering and Kirkbymoorside as well as the huge rural areas of the North York Moors and East Yorkshire Wolds. As a consequence, there are enormous fluctuations in population numbers, which increase considerably during the summer holidays.

Popularity as a retirement destination also leads to particular demands upon health care provision. More than 20 per cent of the population is over the age of 65, against a national average of 15 per cent.  

CONTROL MEASURES
The dramatic reduction in the number of cases of C. Difficile at Scarborough and North East Yorkshire Healthcare NHS Trust came about through various changes in practice and the introduction of a number of control measures, these included:
•    Reducing visiting hours, which is still in operation today
•    Suspending all elective admissions for
a period in January 2010 to reduce bed occupancy
•    An isolation unit was opened in March 2010 with admission and discharge criteria
•    A commitment from the trust board and an additional £500,000 released for improving cleanliness

Measures also included the introduction of HPV environment & equipment decontamination initially via an external company to allow full ward decontamination to take place. This was followed by investment in HPV decontamination equipment and staff training so that deep cleaning could take place internally

Daily executive meetings (which are now fortnightly) and regular walkarounds were introduced, which features a member of the trust board making a series of checks on wards with an infection control nurse

In addition, every commode in the hospital – a total of 130 – were replaced with a new state-of-the-art version, designed for easy cleaning.

The trust adopted the SIGHT principles and changed to the Five moments hand hygiene tool, meanwhile more information about C. Difficile was made available to both staff and patients, through leaflets and staff briefings; coupled with a huge push on hand washing and the use of antibacterial gels

A revision of a restricted antimicrobial prescribing policy also took place along with the launch of an innovative competition called the Wash Factor.

THE WASH FACTOR
A competition was launched during International Infection Prevention and Control week in October 2010 to encourage wards and departments to come up with a song or dance to highlight good hand washing.

The competition was the idea of Donna Winter, infection control nurse, who was inspired to do something creative in order to really push the importance of good hand hygiene.

Donna explained: “Hands are the most common vehicle to transmit healthcare associated infection and it is the role of every single member of staff to ensure that we take hand hygiene seriously.

“With the X Factor and Strictly Come Dancing fever we thought that it would be a good time to hold our own singing and dancing competition, however the twist was that the song or dance had to be about hand washing and infection prevention.  

“Staff could choose to either change the words of an existing song, or come up with an original number. Or they could take a popular dance routine and change the actions.”

Wards and departments were asked to send a short clip of their song or dance to the infection control team and were asked to perform their entry in a live final in December. However, the caliber of the entries was so strong that the judges were unable to make a decision and instead chose four finalists.

A film clip of each of the four finalists performing their entry was professionally produced and staff were invited to vote on who they thought was most deserving of the ‘Wash Factor’ title.    

Maggie and the Mopheads were officially crowned the Wash Factor Winner at the Scarborough Hospital Ball.

Otherwise know as domestic supervisor Maggie Oxley and domestic assistants Janet Lockey, Julie Tayne and Shirley Major, the team scooped first place with their rendition of Three Steps to Hand Hygiene’ which was sung to Eddie Cochran’s 1960’s single ‘Three Steps to Heaven.’
To view the winning video of Maggie and the Mopheads visit http://vimeo.com/18500827.

New antimicrobial prescribing guidelines
New antimicrobial prescribing guidelines in conjunction with neighbouring York Teaching Hospital NHS Foundation Trust were also introduced.

Antimicrobial pharmacist Pam Garnett explained: “Antibiotics don’t cause C. difficile but if someone ingests the infection and are on antibiotics, it can multiply.

“We’ve changed the guidelines to include narrow spectrum antibiotics, which are less likely to encourage growth of C. difficile.

“We’re also doing a fortnightly audit of antimicrobial prescribing and trying to encourage doctors to only prescribe antibiotics when they are absolutely needed.”

Following its success in dealing with the outbreak, the trust was invited to share its experience at a national healthcare conference in Birmingham last month by hosting a masterclass in managing infection outbreaks.

Sue Peckitt, deputy director of infection prevention and control said: “This was a real honour for the trust and was a great accolade for all the hard work and effort that our staff have given.”

THE SITUATION NOW
Year end figures for 2010/11 showed that the organisation had processed 119 confirmed cases of C. difficile and of these 119 cases, 46 were attributed to the trust, placing it 20 cases below its trajectory for the year.

This is in stark contrast to 2009/10 when there were 170 confirmed cases, 77 of which were attributed to the trust.

Sue continued: “This is a phenomenal achievement, but we’ve not done it on our own. All members of staff have worked very hard to achieve this and they should be very proud of themselves.

“However, we are not complacent because we know that at any time it could reoccur. Patients can come to us from the community or other hospitals that already have Clostridium Difficile, so we are trying to work more closely with community staff.

“Our trajectory for 2010/11 is 46 and our priority is to maintain control of the situation so that we can once again meet this target.”