November 13th 2009

The last case of Clostridium difficile was confirmed on the 5th November, there have been no new cases of confirmed Clostridium difficile at Our Lady of Lourdes Hospital since 5th November, 2009.

Since the beginning of October, there have been 21 confirmed cases of Clostridium difficile at the hospital. There are currently 12 confirmed cases.  All confirmed cases were initiated on appropriate treatment for Clostridium difficile and the majority of patients have responded to these treatments. In the same period a further 30 patients were symptomatic with diarrhoea, most of these patients have improved with their management however 15 patients remain symptomatic.

Clostridium difficile is a well recognised Healthcare Associated Infection (HCAI). The Health Protection Surveillance Centre has produced national guidelines for the surveillance, diagnosis and management of Clostridium difficile.

These guidelines are implemented on an ongoing basis in Our Lady of Lourdes Hospital so as to minimise the impact of an outbreak on all service users, staff and the general public. They include (inter alia) guidance on the prescribing of certain antibiotics to prevent infection, case finding, risk assessment of symptomatic patients, isolation of patients who pose a potential or actual high risk of infection to others; mandatory hand hygiene and other infection control measures.

When this outbreak was called an Outbreak Committee was convened in accordance with the national guidelines. The Outbreak Committee sought to learn from national and international experience of similar outbreaks. A due diligence is underway to establish if acknowledged risks in other outbreaks may have contributed to spread in this outbreak.

The Clostridium difficile outbreak in Our Lady of Lourdes Hospital was called on the 28th October. Since then there has been a renewed emphasis on medication prescribing with increased restrictions on the use of certain antibiotics, laxatives and other drugs in line with expert advice available to the committee; three wards in the hospital were identified and used to implement stringent isolation and control measures; there has been targeted emphasis on mandatory hand hygiene and other infection control measures. There is ongoing education of all grades and disciplines of staff to update on the status of the outbreak and measures that staff can take to care for the patients affected, minimize further spread to unaffected patients and contain the outbreak.

The Outbreak Committee has sourced specialists to assist with deep cleaning of affected wards and hospital equipment; specialist engineers have been drafted in from the United Kingdom to decontaminate most of the affected areas of the hospital and these measures will continue on an ongoing basis.

Outbreaks of HCAIs are associated with high occupancy rates in hospitals; This outbreak coincided with a bank holiday weekend when there was considerable demands for inpatient beds. Prior to the outbreak being called a patient with diarrhoea was only classified as potentially having infectious diarrhoea if they had three or more episodes loose/watery bowel motions. This is in line with internationally accepted definitions. It is acknowledged that both of these issues may have given rise to delays in the isolation of some patients.

Since the outbreak was called and given the clinical course for some patients which was consistent with the more aggressive subtype of Clostridium difficile infections (five cases have been confirmed as the 027strain)  a lower threshold for case finding, risk assessment, diagnosis and treatment has been instigated..  This lower threshold may give the appearance of higher than otherwise expected numbers of patients with symptomatic diarrhoea, however the outbreak committee believes that it has resulted in more rapid case finding, prompt diagnosis and treatment and should result in improved patient outcomes.

The HSE acknowledges that the outbreak of Clostridium difficile may cause concern for current or former patients of Our Lady of Lourdes Hospital and their families. The Hospital and HSE management wishes to express their apologies to the patients and their families who have been affected by this outbreak.  Patients or their families who may have questions or concerns about their care at the Hospital can contact the Hospital at 041 9837601 from 9.30am to 5.00pm, Monday to Friday. These calls will be directed to clinical personnel.

Clostridium difficile is a notifiable disease. This means that a Doctor is legally bound to notify the Coroner in all cases where a person has died who may have been exposed to or contracted a Clostridium difficile infection. The Coroner is responsible for determining if Clostridium difficile was the cause of and/or contributory factor to their death.

Since 6th November in consultation with the Louth County Coroner our Clinical Director has agreed that all deaths occurring at the hospital during the escalation phase of the outbreak will be notified to the Coroner as a matter of routine. Prior to 6th November two deaths were notified to the Coroner and since the 6th November, there have been a total of three deaths at the hospital and they have all been notified to the Coroner. We expect that a number of these cases will not be attributable to Clostridium difficile. We have been contacting the families of the deceased and they have been offered appointments to meet with the treating clinician.

Restrictions remain in place at the hospital and GPs and Ambulance services have been requested to refer adult patients, with medical complaints to Louth County Hospital Dundalk, Our  Lady’s Hospital,  Navan or the nearest appropriate hospital. Adult patients with surgical complaints should be
referred to Cavan General  Hospital, Our Lady’s Hospital, Navan or the nearest appropriate hospital.

Members of the public are asked to only attend the Emergency Departments at the hospital in the case of a genuine emergency and to contact their GP or out of hours service in the first instance.

Patients may experience delays in the Emergency Department and regrettably due to the number of beds closed to new admissions we have delays in patients awaiting admission. 91 beds are currently closed at the hospital as a result of isolation and containment measures associated with the outbreak.

Strict visiting restrictions remain in place and where visitors are permitted they are being advised of the need for appropriate hygiene protocols.  As is good practice, all visitors to the hospital are urged to wash their hands thoroughly before and after their visits and to use antibacterial hand gels provided.

Elective admissions and elective scopes have been cancelled until further notice. However, all outpatient appointments are proceeding as normal.

ENDS

Note: Earlier this week the HSE advised that a total of 4 deaths were notified to the Coroner, there had in fact been 5 deaths notified.