Using Root Cause Analysis to tackle
C. difficile infections
Dr. Tony Maggs
Director of Infection Prevention & Control
Torbay Hospital
South Devon Health Care, NHS Foundation Trust
Audio Conference Call
October 13, 2010
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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
13th October 2010: Massachussets CDI Prevention Learning Collaborative
South Devon Healthcare NHS Foundation Trust
Local population of around 280,000
- 25% over 65 (national average 19%)
Torbay District General hospital
3,773 staff (= 3,140 FTE)
450 beds (around 15% side rooms; ≈$150M backlog maintenance)
In top 3 nationally for day case rates
Average length of stay 3.6 days (down from 4.7 in 2004)
Bed occupancy >85%
‘Managed through culture’
SDHFT hospital acquired C difficile infections
1.6
1.4
Rate per 1,000 bed days
1.2
1.0
0.8
0.68 / 1,000 bd
0.6
0.20 / 1,000 bd
(70% reduction)
0.4
0.2
0.0
Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1
2004
2005
2006
2007
2008
2009
2010
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)
SDHFT hospital acquired C difficile infections
1.6
1.4
Rate per 1,000 bed days
1.2
Started RCA
process
1.0
0.8
0.6
0.4
0.2
0.0
Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1
2004
2005
2006
2007
2008
2009
2010
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
http://www.clean-safe-care.nhs.uk/ArticleFiles/Files/CDI_RCA_Tool_F%20.xls
2008 - tried the new tool
• stifled discussion
}
• medics switched off
• ‘closed’ analysis
Very detailed / data driven (eg policy
revision dates & compliance audits)
-> 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
Root cause analysis
Hospital acquired C difficile infection
(10 days)
Root Cause Analysis
Review of standard
practices
(lead by matron)
Action Plan
Serious Adverse
Event Group
(signed off by associate director of
nursing and clinical director)
(for information)
Healthcare Associated Infection Group
(monitored by trust operational group charged with implementing
annual Healthcare Associated Infection Action Plan)
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 were other treatments reviewed?
• How quickly did the lab report the result?
• How quickly was a positive test responded to?
• How quickly was any failure to improve reacted to?
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