Clostridium difficile is an infection of the large bowel which causes diarrhoea and inflammation of the gut. It is often associated with antibiotic use which disrupts the normal bacteria in the gut.
The Clostridium difficile micro-organisms may contaminate the environment, can be spread by hands and consumed on food. It is possible to prevent the development and transmission of Clostridium difficile
by careful antibiotic prescribing, scrupulous cleaning, isolation of patients with Clostridium difficile and hand hygiene with soap and water.
It is not possible to prevent all cases of Clostridium difficile. An increasing proportion of our patients are admitted with Clostridium difficile (carriers). In some cases the use of antibiotics is essential such as patients being treated for cancer with an infection or to treat significant infections. These patients are at risk of developing Clostridium difficile infections when they are given antibiotics.
At UCLH we screen all patients with diarrhoea for
Clostridium difficile unless another cause is known. We screen 20 per cent more patients for Clostridium difficile than trusts generally. This is because early identification and treatment improves patient outcome.
UCLH reported 109 cases of Clostridium difficile
in 2014/15. 80 of these cases have been successfully appealed as not being lapses in care. 20 cases are still under review. Nine cases of Clostridium difficile
have been found to be a lapse in care by the Trust. Therefore we have stayed within our threshold set of 71.
In common with most UK hospitals and in line with national guidance the key interventions used to prevent and control Clostridium difficile by UCLH include antibiotic stewardship and careful review of the continuing requirement for antibiotics; monitoring of stools using the Bristol stool chart for early identification of diarrhoea; rapid stool sampling and testing in the presence of diarrhoea and isolation in a single room until a cause is found or the infection risk has ceased and the use of personal protective equipment and hand-washing.
We also ensure appropriate and timely treatment and support including new treatments such as faecal transplants (see glossary) in persistent infections. We also review the use of Proton pump inhibitors (see glossary) and other drugs which may contribute to the development of Clostridium difficile; use including hydrogen peroxide vaporization and deep cleaning for the enviromment. Information and education of staff, patients and visitors, feedback of learning from
the RCAs (see glossary) and Board level awareness and support of Clostridium difficile reduction efforts are also very important.
MRSA bacteraemia
MRSA bacteraemia is an infection of the blood. The target was zero and UCLH has had three cases this year which is a reduction on last year‘s total of six cases.
This year’s cases were due to poor intravenous (IV) line insertion and care. UCLH now has a nurse specialising in intravenous lines, who trains staff in inserting and caring for lines and who investigates the causes of bacteraemia.
A new tool to improve documentation has recently been introduced and a pack has also been introduced which ensures the samples are taken properly. However, we recognise that still more needs to be done.
Current plans are to recruit and train “champions” from each specialty so that they can monitor and support good IV line care.
2. Improve UCLH wide learning from
Serious Incidents
We aimed to provide monthly safety reports to all clinical areas which include overall incident data and summaries of serious incidents including case studies, and learning to prevent recurrence. We also wanted to encourage serious incident discussions at all quality and safety (governance) meetings.
Regular incident analysis reports have been circulated to staff in the UCLH. The reports include overall incident data and a focus on the areas of highest reporting such as pressure ulcers and medicines. Case studies have been included. The internal Quality and Safety bulletin which is circulated to staff has been used to share learning, from serious incidents in particular. Discussions have taken place with the web team to develop a specific site on Insight, the internal website, for access to information on serious incidents and learning.
A ‘Quality Forum’ in February 2015 was focused on serious incident case studies and the importance of understanding how policies and procedures which affect patient safety are followed in practice.
We reviewed the guidance for staff on what to include in the local quality and safety meetings, ensuring a greater focus on learning from incidents, complaints and claims and this is being implemented.
We undertake multidisciplinary ‘Improving Care walk rounds’ to help staff and management teams to improve their services. The purpose of the walk rounds is not to criticise, but to promote improvement
VEY RESUL TS APPENDIX 2 QUALITY REPOR T APPENDIX 3 ANNUAL GOVERNANCE ST A TEMENT APPENDIX 4 ANNUAL ACCOUNTS
in care, environment and services by coming into the area with ‘fresh eyes’. Questions we always ask staff on the walk rounds are: ‘What was the last serious incident in the division?’ and ‘What did you learn from it?’.
Any immediate concerns and areas of excellence identified by the walk round team are fed back to the divisional management team at a debrief meeting after the walk round. A detailed report of all findings and observations is prepared for the management team and the medical director. The divisions draw up an action plan to address any identified concerns and this plan is monitored by the relevant clinical board.
We promote After Action Reviews (AAR). These were introduced to UCLH in 2008 as a universal approach to improving patient safety and the quality and effectiveness of our services. AAR is a group
discussion which is structured around four simple questions:
What was expected? (there is sometimes no plan but there is always some form of expectation) What actually happened?
Why was there a difference? What can we learn as a result?
These are underpinned by a set of ground rules and specifically focused on seeking to learn after an event rather than blame.
AARs can take many forms, from a very formal three hour meeting to a 10 minute debrief and are being widely used in clinical and non-clinical areas of UCLH and other NHS organisations.
AAR is now established as widespread practice with front line teams as a learning and debrief tool.
APPENDIX 2 QUALITY REPOR T APPENDIX 3 ANNUAL GOVERNANCE ST A TEMENT APPENDIX 4 ANNUAL ACCOUNTS
Priority 3: Clinical outcomes
1. Improve our performance on hospital mortality
The SHMI (Summary hospital-level mortality indicator) is the ratio between the actual number of patients who die following hospitalisation at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated here. It includes deaths which occur in hospital and deaths which occur outside of hospital within 30 days (inclusive) of discharge – ‘external SHMI.’
The Health and Social Care Information Centre (HSCIC) release the external SHMI every quarter but there is a six month time lag. The latest external SHMI released in April 2015 was for the period October 2013 to September 2014. A review of the SHMI analysis for the period covering July 2011 September 2014 is shown below.
In addition to the above, we also monitor an ‘internal SHMI’ which only includes deaths in hospital. This data is available to us on a monthly basis and does not have a time lag.
Since 2013, we have seen an increase in the Trust’s external SHMI whilst the internal SHMI has remained relatively steady.
The chart below shows the trend of the external SHMI over time (a lower number is better):