PROCDEURAL SKILLS SCENARIO – INFECTION CONTROL

Examiner instructions:

You are the examiner for this station, in which the candidate has nine minutes to discuss how
they would manage a case of Clostridium difficile with the consultant microbiologist. You
should listen to the candidate talking through their suggested management and score as
appropriate.

After six minutes you should ask them the questions on the next page and mark them
against the suggested answers given. It is appropriate to ask questions while they are
continuing to perform the task. If you feel the candidate is not performing the station
correctly you may invite them to re-read the instructions.

Below is a suggested procedural structure, but the candidate's method may vary. The
important point is that the procedure is performed safely and accurately proving that it could
be done on other patients.

Initial steps:

The patient needs to be prioritised and it should be ensured that the patient is well, and
being managed appropriately. Candidate should carry out the following initial steps:
• Clinically review the patient using an ABC approach.
• Assess the observations, including fluid balance status.
• It is good practice to re-check blood results, especially the renal function and
electrolytes, given the loss of fluid with the persistent diarrhoea.
• Review the need for ongoing antibiotics: What was the initial indication? Is this now
treated? Can the antibiotics be stopped?
• Consult with the infection control team to inform of the positive result, as this is an
outcome that is monitored closely in the NHS and a root cause analysis may be
required.

Isolation measures:

• The patient must be moved promptly from a general ward area to a side room (note:
this should occur with the onset of diarrhoea, rather than when the results are
received).
• Clinicians and visitors should employ strict hand hygiene after seeing the patient
(alcohol gel will not suffice; soap and water must be used).
• When visiting the patient, staff and visitors should wear a protective gown and
gloves.
• If the patient is due to undergo tests in another department (such as radiology or
theatre), they must be immediately informed so that they can institute protective
measures (such as placing the patient at the end of the list).
• If required, single-use disposable equipment should be used.
• The patient needs to understand what is happening and reasons for instituting these
precautions.

Treatment options:

First, the patient should be fully assessed and resuscitated accordingly. Advice from a
microbiologist should be sought with regards to the optimal treatment for Clostridium
difficile depending on the nature of infection:
• mild to moderate disease: oral metronidazole
• severe disease: oral vancomycin
• severe and complicated disease: oral vancomycin and surgical review, as the patient
may warrant a colectomy.
 Scenario-specific instructions:

1 What other infections require isolation?

Bacterial:
• methicillin-resistant Staphylococcus aureus (MRSA)
• Escherichia coli 0157
• Mycobacterium tuberculosis
• Group A streptococci
• Haemophilus spp.

Viral:
• viral gastroenteritis (such as norovirus)
• respiratory syncytial virus
• influenza virus
• mumps (mumps rubulavirus)
• rubella virus
• varicella zoster (chicken pox or shingles)
• tropical viruses (such as Ebola).
2 Are there any groups of non-infective patients that commonly require
isolation?
• Neutropenic patients.
• Immunocompromised patients.
• Patients undergoing significant or whole-body irradiation.
• Patients exposed to chemical toxins (such as polonium, nerve gas).
• Patients who are at very high risk of significant morbidity due to
infection from other nearby patients are kept in specific pressure-
positive rooms as part of a process termed ‘reverse isolation’.
3 What does the term 'aseptic technique' mean?
This is a process that aims to reduce the likelihood of contamination from
harmful pathogens.

4 What does 'sterilisation' refer to?

This is a process that is utilised to destroy all microorganisms, including
bacteria, viruses, fungi and spores.

5 What are the different methods for achieving sterilisation?

Different techniques are used for different instruments, products and scenarios;
however they all achieve the same result:
• autoclave (steam)
• boiling
• pasteurisation
• incineration
• radiation.
 Examiner mark sheet:

Domain Mark
Clinical knowledge 0–20
Demonstrates knowledge in the essential areas tested.
Demonstrates knowledge in the majority of areas examined.
Answers questions concisely and accurately (give 2 marks per question).

Examiner overall assessment

Fail Borderline Pass