Interview with Dr. Andrew Seaton (Part 1)

Hello. Today I’ve come to meet with Dr. Andrew Seaton, Lead Clinician for the Antimicrobial Management Team in Glasgow, to discuss how his team used a quality improvement approach to address a serious Clostridium difficile infection outbreak. Andrew, can you please tell us, first of all, about the background to this problem and how you knew that antimicrobial use was not as it should be? Well, this was back in June 2008. It became apparent at that time in one of our hospitals– the Vale of Leven Hospital– that there was an unusually high rate of Clostridium difficile, and over a six-month period this became apparent there was a high mortality associated with the Clostridium difficile, and we realised there was a problem.

Obviously there was an investigation, and there were various infection control issues that were unearthed, but at the same time we– through our antimicrobial pharmacist and our antimicrobial management team– we investigated use of antibiotic therapy. And our investigation essentially– this was done very rapidly– and looked for use of the broad-spectrum antibiotics that we normally associate with Clostridium difficile. And what we found was slightly higher rates of co-amoxiclav use, cephalosporin use and quinolones used in this one hospital, and we did a fairly rapid comparison with some other neighbouring hospitals within that region and found that, within this particular hospital, it was slightly out of step, and there was more prescribing of these agents.

But we were also concerned at the same time that this problem might be more of an endemic problem within all our hospitals, so we were cognisant that maybe any changes that we would have to implement to help with controlling the C diff outbreak would have to be, not just on that one single hospital, but brought about more broadly. It’s important to say at that time we didn’t have a very formalised antimicrobial stewardship programme. We had a small team that was just starting to be developed, and that was a time when we were just starting to unify our antimicrobial guidelines across all nine of our acute hospitals.

So this was really an early stage, and because we were a very small team, it was essential that we had participation with the clinicians and the clinical pharmacist to help both gather the data and also to help us take forward the changes that we were about to make. So it sounds like you had a serious problem on your hands that needed some great widespread action to tackle it, and could you just tell us a bit about what your aim was and who you had to involve in the process. So the aim was really twofold.

First of all, to implement change locally in order to ensure that we were controlling Clostridium difficile in the Vale of Leven Hospital and associated hospitals and, secondly, to think about the implications more broadly for our nine acute hospitals within our health board. So to make an understanding that the problems that were happening in this hospital potentially could be happening elsewhere. So the immediate aim was to design guidance that was going to restrict antibiotics implicated in C diff and implement that locally in the hospital, and that required engagement with clinicians, clinical pharmacists, nursing staff, and it needed to happen quickly.

I should mention that at this stage, there was a lot of– there was going to be publicity about this as well, and we were really also under the media spotlight, and it was important, not only from that point of view, but just from a clinical safety point of view to just ensure that we get on top of this problem very quickly. So we convened a very small group really very rapidly with clinical microbiologist, infectious disease physician, and clinical pharmacist– an antimicrobial pharmacist– to look at the current guidance and to see in what way we could restrict it to make C diff less likely. So we used the best evidence we could.

We restricted cephalosporins, co-amoxiclav, clindamycin, and the quinolones and produced very rapid guidance, which we then implemented– really within 48 hours of our involvement– on the wards, through hospital meetings, through engagement with clinicians, clinical pharmacists, nursing staff, and managers. And we got very good engagement very rapidly, because the clinicians realised that this was a very serious problem and something that we needed to get on top of quickly. We also took more draconian measures in that we removed drugs from the wards.

So certain drugs, like cephalosporins particularly, could only be made available on the recommendation of an infection specialist, so whereas these had been freely available for a number of indications prior to that, they now could only be got through requesting through an infection specialist or directly at the recommendation of an infection specialist. So that was the first step. The second step was really to learn immediately from this and to amplify our understanding and amplify our intervention across all nine acute hospital sites in our health board. So we convened an extraordinary meeting via the health board medical director with all the senior clinicians representing different specialties, the senior clinical pharmacists, and senior members of nursing staff.

We got everybody together with management representatives to explain the issue in this particular hospital, the implications for the other hospitals in our health board. So I think there was a real understanding that what was happening in this particular hospital wasn’t too far removed from what potentially was happening in other hospitals under our remit, but also potentially much more widely in NHS Scotland also. So that seems like a good course of action that you took there, with local action first and then spread out to the other hospitals, but how did you ensure that this was communicated effectively to all staff, and also how did you know that it had actually been implemented?

So the first thing we did, really, was we had an email communication with all clinicians, including all consultant clinicians, junior doctors, senior nursing staff, and clinical pharmacy. So we actually had email the guidance to everybody. We posted the new infection management guidelines on our hospital intranet. We made posters available, which we put up on all the clinical area walls. These were all put up by our clinical pharmacists, so there was a lot of involvement across disciplinary working to make all this happen.

We also held hospital meetings very rapidly, not only in the Vale of Leven Hospital, but in the neighbouring hospitals within that area. Within the Clyde hospitals we held hospital-wide meetings to allow everybody to understand why we were making these changes and to give them a chance to voice any concerns they may have. And then, more broadly over the next few weeks, we held hospital meetings throughout NHS Greater Glasgow and Clyde, so across all the different hospital sites. So there was continuing engagement and engagement with various clinicians. We also ensured that all our new guidance was introduced into junior doctor induction.

We set up regular tutorials for doctors within their educational programmes, so each doctor would get at least one clinical session on infection management, which would highlight the infection management guidelines during every six-month block.