Plans To Extend Clostridium Difficile Reporting, Wales Chief Medical Officer Announces

Main Category: Infectious Diseases / Bacteria / Viruses
Also Included In: Public Health;  Primary Care / General Practice
Article Date: 23 Jul 2008 - 0:00 PDT

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A plan to extend the mandatory surveillance scheme for Clostridium difficile has been unveiled by the Chief Medical Officer for Wales Dr Tony Jewell.

Currently only information on patients aged 65 and over is published, but this will now be extended to cover all confirmed cases of the infection in patients aged two and above.

The Welsh Assembly Government will also issue a new protocol for testing for C.difficile to ensure consistency across Wales.

The new measures follow expert advice from the Welsh Healthcare Associated Infection team at the National Public Health Service for Wales and Welsh Assembly Government health professionals.

The data will be published for the first time in September on the number of patients confirmed with C. difficile between January and the end of June 2008. Following an evaluation of the data, this will form part of the routine health associated infection publications in 2009.

Dr Jewell said: "Up to three per cent of healthy adults carry C. difficile and generally it causes them no harm. All patients over the age of two who are suspected of having antibiotic associated diarrhoea are routinely tested for C.difficile and the laboratory results are recorded but not published.

"This has been because the evidence clearly shows that C. difficile is a particular risk to older people who account for 80 per cent of cases. But due to concerns about the increased rate of C.difficile in the over two age group in England, the Assembly Government asked the Welsh Healthcare Associated Infection team to look at how data can be published in Wales for surveillance and benchmarking.

"It is not easy to compare data between Trusts, because the incidence of infection depends on a range of factors, including the age of the patients being treated and the type of services provided.

"To ensure consistent reporting of C. difficile, a new protocol is being developed for when and how to test for this infection. This will enable us to compare data more effectively. We will also be looking at publishing information on the severity of the infection for the patient."

Health Minister Edwina Hart added: "We must remember that the vast majority of patients receive safe and effective care, and the risk of developing any type of healthcare associated infection is low.

"Our strategy for tackling all infections, which has been endorsed by the Wales Audit Office and Assembly's Audit Committee, is paying off with lower infection rates in Wales. But we are not complacent and are working hard to drive them down even further.

"While they will never be entirely preventable, there are measures in place to reduce the risk and spread of infection. Healthcare Inspectorate Wales, the independent organisation set up to inspect NHS settings, has appointed a number of peer reviewers to look at Trusts' infection control procedures and the unannounced hospital cleanliness spot-checks will continue.

"In addition, reducing infections is a key theme in the 1,000 Lives Campaign, which was launched in April. This aims to reduce avoidable risk to patient safety by implementing new ways of working and techniques developed by clinicians in Wales.

"My recent announcement to give extra power to hospital ward sisters and charge nurses on ward cleanliness and hygiene and to restrict patient visiting hours will also help to reduce infections."

Wales has a raft of mandatory surveillance schemes for healthcare associated infections, the first of which was started in 2001. The underlying reason for developing the surveillance schemes is for them to be indicators of the local burden of disease and track trends for local organisations who can then assess their own performance and adjust their own procedures when problems are identified. Comparisons between different hospitals are not straightforward as each one has a different mix of cases, age groups and treatment pathways. The important thing is that the local services are responding to their own position. The Welsh scheme includes feedback to the hospital trusts on a quarterly basis so they will know their own position relative to where they were this time last year and the year before and so on, giving them a clear indication of whether their own processes are working.

The C. difficile mandatory surveillance scheme was started in January 2005 and, on clinical experts' advice, was designed to collect data on the over 65s because this is the group with the highest incidence and the greatest morbidity. There are rules which guide who gets tested, namely all stool specimens coming from inpatients aged over 65 where the specimen is so loose that it conforms to the shape of the pot it is in. The reason for these rules is to avoid confusion with healthy carriers, where C.difficile is present but is not causing illness. Clinicians are also able to request testing for C.difficile in any of their patients and positive tests in those cases aged over 65 years are included in the surveillance scheme, on the basis that the clinician is concerned that C.difficile may be causing a problem in this particular case.

The Welsh Healthcare Associated Infection Group recommended an expansion of the current surveillance and publication system for C. difficile.

The recommendations, which the Health Minister has accepted, are:

• Expansion of the mandatory surveillance scheme to include all inpatients 2 years and above. (A high percentage of Clostridium difficile are colonising organisms in the under 2 year age group and not clinically relevant)

• Enhanced surveillance information linked to strain typing to be collected on a percentage of cases from each laboratory.

• The development of an agreed protocol for the laboratory testing of specimens for Clostridium difficile from all patients of whatever age. It is recognised that standardisation of testing is required to produce comparable data.

All positive C.difficile tests across Wales are captured by the electronic database Datastore. There were 738 cases of C.difficile in the age over 2 to under 65 in 2007, compared to 2799 in the over 65s, ie the young age groups accounted for 21% of all cases. At present, all published data refers to specimens taken whilst the patient is an inpatient. Consideration is being given to the feasibility of publishing data on community samples.

Regarding presenting the results in the same format as England, discussions have taken place with Health Solutions Wales, the organisation that provides the hospital use statistics for the surveillance schemes, to move to getting the same denominator data ie the bed days, or total number of days spent in hospital by patients in the two age groups for each trust, to allow the appropriate calculations to be made. We would still also use the number of cases by number of admissions as this is a meaningful statistic which can be easily understood by clinicians and the public.

Llywodraeth Cynulliad Cymru (The Welsh Assembly Government)
http://new.wales.gov.uk