ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST

LEARNING FROM THE HEALTHCARE COMMISSION INVESTIGATIONS INTO OUTBREAKS OF CLOSTRIDIUM DIFFICILE AT MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST

November 2006

Introduction

The Healthcare Commission conducted an investigation into Maidstone and Tunbridge Wells NHS Trust following a major outbreak of Clostridium difficile to assess the care provided to patients with this infection. It also considered whether the Trust’s systems and processes for the identification, prevention and control of infection were adequate. The Trust had a relatively high rate of infection with Clostridium difficile over several years but no one in the Trust or the local health community was aware.

Findings

The Trust’s guidelines for the management of Clostridium difficile were not sufficiently clear about the importance of effective isolation of patients with the infection and their policy for responding to outbreaks was not fit for its intended purpose. The infection control team were keen to isolate patients with Clostridium difficile but the scarcity of side rooms made this difficult.

The Trust had not reviewed its antibiotic policy following the letter from the Chief Medical Officer and Chief Nursing Officer in December 2005 and examples were found where there was unnecessary antibiotic prescribing to vulnerable patients.

Once a patient was diagnosed there appeared to be a lack of monitoring and treatment of the infection and this may have been because doctors and nurses failed to appreciate that infection with Clostridium difficile can in may cases become a potentially life threatening illness. Patients and their families were unhappy about the care received, bells were not answered and patients were told to go in the bed rather than be taken to the toilet or given a bedpan. Some patients and relatives also reported that the information the Trust gave them about Clostridium difficile was poor.

The individual appointed to be the director of infection prevention and control (DIPC) had insufficient understanding of the role at the outset and failed to gain sufficient knowledge about procedures and processes in other Trusts. There was no strategic direction for the infection control team and confusion about who managed the team. Training on infection control was poorly attended and the infection control policies were nearly all out of date.

Many of the buildings were old and in a poor state of repair and the beds on several wards were much too close together, making it difficult to clean. The Trust had a history of low staffing levels and a relatively low proportion of qualified staff and relied heavily on bank and agency staff.

There had been considerable change in the structure and responsibilities relating to governance and the management of risk, leading to confusion over accountability. The risk register and assurance framework were not well understood. Staff had little confidence that reporting incidents would lead to change. The system that was intended to bring clinical risk to the attention of the Board did not function effectively and the Board appeared to be insulated from the realities and problems on the wards.

Conclusions

The Trust had no effective system for the surveillance of Clostridium difficile and therefore missed an outbreak. The clinical management of the majority of patients with Clostridium difficile fell short of an acceptable standard in at least one aspect of care.

Antibiotics need to be seen, like all medication, as potentially dangerous drugs and only prescribed if there is a clear clinical indication and reviewed daily. All patients diagnosed with Clostridium difficile needs to be respected as a diagnosis in its own right and managed accordingly.

Recommendations

The Trust Board is asked to endorse the attached action plan (Appendix A) and to monitor its implementation by receiving quarterly updates or more often if required.

Kathryn Corder

Acting Director of Nursing

November 2007

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