The new targets are realistic and should act as a strong incentive for infection control teams and healthcare staff to continue their good work; Trusts with low CDAD numbers are providing the best care possible. Trusts with high CDAD numbers still need to improve by investing in infection control as well as microbiology and infection teaching at all
For example, a patient with diarrhoea on admission (obviously community acquired) has a stool specimen taken by hospital staff 4 days after admission which is positive for Clostridium difficile. It now has “become” a hospital acquired Clostridium difficile case purely due to the delay in taking the specimen! If this is over target it will cost the Trust £50,000 per case. Ouch, whose budget does that get taken out of? If the specimen had been taken on admission, the stats would show a community acquired Clostridium difficile, it would not count against the Trust nor would they receive a fine. More importantly the patient would have been isolated and on appropriate treatment sooner. The new guidance would mean the Co-ordinating Commissioner (who is responsible for ensuring the work of the Trust is carried out and paid for) will have the discretion to either count or not count cases against the Trust’s target for sanctions based upon whether there has been a “lapse in care”. In this case there was a lapse in the patient’s management, so it would still count against the Trust. Here, lessons need to be learnt to improve the diagnosis, speed at which this specimen was taken (4 day delay is not acceptable), improve infection control and the isolation of patients and speed up the initiation of treatment.
However, consider this example, a patient is admitted with a CVA, develops a UTI and is treated with Trimethoprim for 3 days. The specimen confirms a Trimethoprim sensitive E. coli and the patient’s UTI is treated successfully. Two days later they develop diarrhoea, a stool specimen is sent and the patient is immediately isolated. Healthcare staff follow good hand hygiene and the prescriptions are all correctly documented with indications and stop and review dates. The specimen is positive for Clostridium difficile. Under the old guidance the Trust, if over target, would be fined £50,000 even though this treatment was exemplary; this patient may have been a carrier of Clostridium difficile. Fining the Trust in this case damages the morale of healthcare staff and does not help improve standards. Under the new guidance the Trust will still report the case but the Co-ordinating Commissioner has the discretion not to count it against the Trust’s target, avoiding the fine, as the Trust showed no lapse in care. This discretion still promotes good care, maintains high standards but essentially keeps staff morale high.
breaching targets has also changed. Previously the fine was a crippling £50,000 per case over target, (two cases over target a year is equivalent to the salary for an extra Consultant Microbiologist); from April 2014 the fine will reduce to a more realistic £10,000 per case.
The diagnosis and management of patients with Clostridium
difficile associated Disease (CDAD) hasn’t changed. Recommended investigation is still a 2 stage test based on either Glutamate Dehydrogenase (GDH) or PCR followed by toxin detection, and treatment is still either PO Metronidazole (1st line) or PO Vancomycin (for severe disease). So this new guidance may seem “policy” rather than affecting the day-to-day impact of medical teams,
however, it should mean teams are less likely to be in route-cause analysis meetings, up in-front of Trust Boards and facing financial squeezes on their budget which ultimately affects patient care. It is not however time for complacency. Pat ourselves on the back? YES certainly, but without investment and implementation of infection control, as well as microbiology and infection teaching at all levels these targets will not be maintained.
The future of CDAD may lie in testing on admission. A quick and efficient test which could show if the patient is a carrier allowing: 1) a better understanding of the epidemiology of Clostridium difficile , 2) isolation of Clostridium difficile carriers ensuring better infection control and 3) Trusts to eliminate carriers from counting against targets.
You can see the guidance and targets for your Trust at the link below: http://www.england.nhs.uk/ourwork/patientsafety/associated-infections/clostridium-difficile/