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Some hospital staff were reprimanded for not following infection-control protocols. ((CBC))

Some doctors, nurses and janitors were not following rules to prevent the spread of C. difficile during an outbreak that saw four patients die in Cape Breton, documents show.

The documents, obtained by CBC News, describe how the battle with a hypervirulent strain of C. difficile played out in the Cape Breton health district earlier this year.

Clostridium difficile are bacteria commonly found in the intestine, but infections can be life-threatening for those taking antibiotics or who have serious pre-existing health issues.

The bacteria are often picked up in hospitals. Workers can spread it by touching something – like a doorknob – if they don't wash their hands.

The documents show that some staff at Glace Bay General Hospital and Cape Breton Regional Hospital in Sydney didn't follow infection-control protocols, such as donning new gloves for each room or properly disposing of protective equipment.

At one point, the Cape Breton District Health Authority brought in public health nurses to educate hospital staff.

"A very small number of people who had received the education chose to ignore it," said John Malcom, health district CEO.

"We did issue letters of warning and reprimand and would've taken more concrete action if it had reoccurred."

This was Nova Scotia's first experience with NAP 1, a particularly virulent strain of C. difficile linked to up to 3,000 deaths in Quebec.

The documents show there were 49 serious cases in Cape Breton, though the Public Health Agency of Canada hasn't released final numbers yet.

3 of 4 deaths in Glace Bay

What is known is three of the deaths in Cape Breton were at the hospital in Glace Bay and one at the hospital in Sydney. All were on the surgical floors.

The three elderly patients in Glace Bay all died in February. They were admitted for various reasons, including one for back pain.

That month, the number of C. difficile cases jumped. There were 14 confirmed cases in hospitals, up from an average of three to five a month. On March 3, health officials held a special meeting to discuss the outbreak.

There were no more deaths in Glace Bay after the hospital got the outbreak under control at the end of February, and that gave the health authority a false sense of security, said Malcom.

"That actually sort of gave us the impression that we had caught this, that we had stopped it, and then it migrated to the Regional," he said.

In Sydney, the C. difficile infections were focused on the fourth floor of the hospital, where a man died March 15.

On March 17, a memo was sent to all unit managers and directors saying that NAP1 was circulating. The next day, an urgent memo went out to all physicians.

In another memo two days later, all department members were warned that the strain had "become a huge source of morbidity and may lead to patient deaths."

In March, there were 15 infected patients, according to the documents.

Health officials tried to prevent further cases. They said patients with C. difficile were to be placed in private rooms and have their own dedicated equipment or bedpans. The rooms were to be cleaned with bleach twice a day. Everyone was to wash their hands with soap and water.

Deficiencies found

Infection-control auditors that were brought in found a number of deficiencies, including areas that weren't cleaned well enough or with the right equipment.

Some janitors were using spray wands to clean toilets and bedpans, which can spread the bacteria. In one suspected case, the patient was sharing a toilet in a four-bed ward.

Patsy Rawding, an infection-control consultant, said there was room for improvement.

"Do you realize when you have your gown, glove and mask on, what you do with your gloves and where you touch and how to take it off [make a difference]. So it's always a great opportunity to have refreshers," she told CBC News.

Malcom isn't surprised that some doctors did not follow the infection-control protocol.

"We know from studies that have been done that doctors tend to be the least compliant with infection-control practices," he said.

The health district has spent more than $550,000 to implement changes  to prevent another deadly outbreak.

Malcom said they need another $2 million from the Nova Scotia Department of Health to cover renovations, such as installing more sinks and replacing floors.