The hospital acquired C-diff is a new strain of the bacteria normally found in the human bowels and has become virulent, causing severe diarrhea. Of course the elderly and newborns are the most susceptible because of the resultant dehydration and electrolyte imbalance. When it comes to outbreaks of infectious disease the one environment left in our society where epidemics are rampant with no controls in sight is the hospital.

Although hospitals by nature draw people with infectious disease, there is a concentration of professionals with the skills to prevent or at least quickly contain the outbreaks. That is why an uncontrolled epidemic is scandalous. To wit, there is a set of standards requiring continuous action to identify, contain, and prevent epidemics. Yet the number of deaths per year due to hospital acquired infections is on the rise, accordance to the

Center Of

Disease Control and Prevention (CDCP).

Moreover, this new bug called "C-diff" is proliferating in hospitals at an alarming rate. The mortality rate is even more disquieting and this new scandalous outbreak is like to cause the death rate due to hospital error to skyrocket even further.

The epidemiology experts are telling us once again that it all boils down to hand washing between patients and maintaining sterile technique during invasive procedures. There is great concern that since the C-diff causes severe diarrhea, there is likely to be a higher incidence of fecal contamination of sterile fields, food, equipment, linens, etc.

Finally, the overriding question for the legal community is "What constitutes provable negligence when the cause of death or protracted illness is HAI?" The answer is that there are standards of care regarding the infection prevention and control (IPC) process and the sterile technique of invasive procedures. In this blog we shall focus on the former, leaving the latter for the next issue.

First, every institution must have an IPC department with a set of policies and procedures for identifying potential and real outbreaks. Such activities include but are not limited to:

1. identifying the source of the outbreak with cultures;

2. providing appropriate isolation;

3. keeping statistical data;

4. identifying risks and risky behaviors;

5. screening for MRSA and C-diff prior to elective surgery

The following is a portion of an actual infection control report provided to a hospital board of trustees and provides clear insight as to current standards of care.

Infection control measures already instituted

• Regular hand washing demonstrations on wards

• Continued hand washing audits

• Continued MRSA screening for all elective orthopedic patients and for patients admitted from nursing homes

• Invitation to DOH [department of health] team to review MRSA procedures (scheduled for first week in July)

• Continued intravenous access monitoring and audits

• Prescription of all antibiotics to be restricted to 5 days with the prescription extended only after consultation with a microbiologist

• Monitoring of antibiotic prescriptions by pharmacists – initially on 48 hour ward and to be spread to other wards in the future after audit results available and when pharmacy staff are up to full strength (current sickness has reduced pharmacy availability)

• Curtailing of use of Co-Amoxiclav

The use of broad spectrum antibiotics has been implicated in the appearance of C. difficile. Co-Amoxiclav has been shown to increase this likelihood when compared to organism specific, narrow spectrum antibiotics. After seeking microbiological advice, this antibiotic has been withdrawn from general use and will only be available on a named patient basis or in specific cases, such as animal bites or in life-threatening circumstances.

Infection control measures proposed

• A specific team to be created for the insertion of CVP lines and IV feeding lines

• Possible regularization of, and reduction of, visiting times (PPI forum audit results supports restriction of visitors to 2 at any one time and standardization of visiting times across wards)

• Web-based training material to be available to all SWGHT staff with introduction of infection control in mandatory training requirements

Principle risks identified

• Ward managers not taking responsibility for hygiene standards in their areas of clinical activity

• Continued lack of permanent microbiology consultant staff

• less than optimum allocation of microbiology consultant time to facility.