Infection Control for the Infection Control for the Prevention of Prevention of Clostridium Clostridium

difficiledifficile (C.diff) in the (C.diff) in the hospitalhospital

Quality Improvement ProjectN607 Program EvaluationSummer 2010

Area for Quality ImprovementArea for Quality Improvement

Increase compliance with contact precaution protocol for all health professionals in contact with suspected or confirmed cases of C. diff.

Clostridium DifficileClostridium Difficile

What is it?◦Also known as C.diff: a spore forming, gram-

positive anaerobic bacteria◦Releases Toxin A, Toxin B◦Can cause diarrhea◦Accounts for about 15-25% of antibiotic

associated diarrhea.

Why is C.diff a problem?Why is C.diff a problem?2004, new epidemic strain of C.diff emerged

causing hospital outbreaks in several states

More virulent strain, more resistant to flourquinolones

C. diff affects about 500,000 Americans/yr, contributing to about 15-20,000 deaths

C.diff associated with healthcare (80%)

Rivals MRSA as top emerging disease threat

Contributes to escalating costs of healthcare

Clostridium DifficileClostridium DifficileSigns/Symptoms

◦Watery diarrhea◦Fever◦Loss of appetite◦Nausea◦Abdominal pain/tenderness

Risk Factors◦Long term antibiotic use◦GI surgery/manipulation◦Long-term stay in healthcare setting◦Immunocompromised conditions/Underlying

health issues◦Change in infection control practices

Chain of InfectionChain of InfectionInfected patient sheds bacteria in feces

Fecal/oral route

Bacteria can form spores, contributing to ability to survive in environment for months, possibly years

Patients who have recovered from C.diff are still shedding bacteria unknowingly

Healthcare worker to other patients◦ Hands of healthcare workers ◦ Environmental reservoirs of the bacteria

DoDo

StudyStudy

ActAct

YesYesPatient suspected of C. diff?

Patient suspected of C. diff?

Utilize Standard

Precautions

Utilize Standard

Precautions

Obtain stool sample

Obtain stool sample

Send to laboratory

STAT

Send to laboratory

STAT

Initiate C. diff protocol

Initiate C. diff protocol

Results positive for C. diff?

Results positive for C. diff?

NoNo

NoNo

YesYes

Continue C. diff protocol

Continue C. diff protocol

Start/End

Decision

Action

Flowchart KeyFlowchart Key

Discontinuation of C. diff protocol?

Discontinuation of C. diff protocol?

NoNo

YesYes

Limit indiscriminate

use of antibiotics

Contact precautions

Environmental cleaning

ReassessmentReassessment

Flow

Education

Spread of C.diffSpread of C.diff

People

Environment Supplies

Fishbone Diagram: Spread of C. Diff.

Hospital personnel not updated on C. diff protocol

Epidemiology not understood

Noncompliance to C. diff protocol

Patient and visitors unaware of C.diff prevention measures

• MD• Nurse• CNA• Environmental Services• Hospital Staff

Spread of C. diff

Spread of C. diff

Education

Improper hand hygiene

Spread of C. diff spores

Cleaning staffVisitors

Nurses

Improper hand hygiene

High patient load

Non-compliance with contact precaution protocol

Stress

Lack of time

Inadequate cleaning

• wrong cleaning solution• unaware of patients with C.diff• unaware of C. diff cleaning protocol

Shortage of supplies

• unaware of C.diff protocol• noncompliance

unaware of C. diff protocol

People

Hospital staff

Patient

Spread of C. diff

Spread of C. diff

Immunocompromised.

Spread of C. diff

Spread of C. diff

Environment

Supply room location inconvenient

Improper cleaning

Sink location inconvenient

Lack of single rooms

supplies and dedicated equipment not stocked in patient rooms.

C.Diff spores left on surfaces

next patient or staff touches spores

staff spread spores to immuno-compromised patient

immunocompromised patient is assigned room and becomes infected

greater likelihood of infection

Staff less likely to wash hands with soap and water

Spread of C. diff

Spread of C. diff

Supplies

Lack of patient specific equipment

• gloves • gownsImproper cleaning solution

PPE equipment not replenished

spores remain on common areas

spores remain on community equipment

spores get passed to other patients

hospital staff come in contact with spores

Cause Analysis: Points of WeaknessCause Analysis: Points of Weakness

Education◦“A study at one hospital found that 39% of

resident physicians and other medical personnel didn’t know that C. diff spores could be transmitted from patient to patient on equipment.”

Bertram, C., 2010

Cause Analysis: Points of WeaknessCause Analysis: Points of WeaknessPeople

◦Nurse patient assignments are overwhelming – nurse does not have

time to follow protocols Nurse does not see the value in washing hands because she used

gloves Nurse does not use gown when coming into contact with patient

feces Nurse does not wash hands thoroughly with soap (alcohol does

not kill C.diff spores)

◦Visitors Do not use contact precautions when visiting Are unaware that contact precautions are needed

Cause Analysis: Points of WeaknessCause Analysis: Points of Weakness

People◦Cleaning staff

Cleaning staff does not take special precaution in cleaning room Cleaning staff does not know that the room was occupied with a

patient with C. diff Cleaning staff does not know how clean a room inhabited by a

patient with C. diff Cleaning staff does not have the proper cleaning solution

Lessons Learned at HomeLessons Learned at HomeUniversity of Pittsburgh Medical Center,

2000, annual rate of C. diff infection from 2.7 to 7.2 per 1000 patients◦ Comprehensive strategy for rigorous cleaning with bleach◦ Rapid identification & isolation of C.diff pts to prevent

spread◦ By 2006, C.diff rates down by 71%

Intermountain Healthcare, UT, 2005: 8 infants in NICU died of C.diff infection◦ Launched extensive cleaning program◦ Extensive staff education on C.diff◦ Education on hand hygiene with soap/water◦ Results: No C.diff cases in NICU for next 2 years

Lessons learned from AbroadLessons learned from Abroad Stoke Mandeville Hospital, UK (2003-05) Maidstone & Tunbridge Wells NHS, UK (2005-06)

◦ Both failed to implement existing guidelines and protocols for infection control.

◦ Both had recently undergone difficult merger, mgmt not focused on clinical issues

◦ Poor pt care environment: old buildings, high levels environmental contamination

◦ Equipment contamination◦ Poor hygiene◦ Lack of single rooms◦ Nursing shortage

Chlorine-releasing agents more effective than detergents for killing spores produced by C.difficle. (MacLeod-Glover, Sadowski, 2010)

StudyStudy

PlanPlan

ActAct

Interventions for everyone Interventions for everyone (nurses, physicians, (nurses, physicians, environmental staff, ancillary environmental staff, ancillary staff)staff)

Education on hand hygiene◦ Soap and water only. No alcohol based gels.◦ Only friction with hand washing to displace spores.◦ Complete drying of hands with paper towels.◦ Hand washing even with the use of gloves◦ Hand washing when entering and exiting the room◦ Adherence to 5 moments for hand hygiene

Interventions for everyone Interventions for everyone (nurses, physicians, environmental (nurses, physicians, environmental staff, ancillary staff) cont.staff, ancillary staff) cont.Contact precautions

◦ Disposable gloves and gowns should be worn with all contact with C. diff patient and their immediate environment

◦ Extra care should be taken when handling bedpans/urinals.

◦ Follow proper hand hygiene protocol. ◦ Contact precaution sign on patient’s door

Epidemiology◦ Spore formation and its spread.

Interventions for NursesInterventions for NursesEducation Nursing staff

◦ Patient Placement private room vs. cohort

◦ Dedicated equipment stethoscopes, thermometers, BP cuffs

◦ Immediate testing of suspected C.diff patients◦ Responsible for effective communication to others.

Limiting visitors Informing Environmental Services Place contact precaution sign on door.

Interventions for Environmental Interventions for Environmental Services (EVS)Services (EVS)

Dedicated cleaning staff◦ Responsible for cleaning every C. diff room.◦ Responsible for daily cleaning of units with C. diff pts

resides (halls, curtains, if soiled, computers, furniture, nursing stations, rest areas, all high touch surfaces in pt’s room)

Special training on C. diff infection

Use of chlorine-releasing agents

Provide FAQ sheet on C.diff

Interventions for Interventions for PatientPatient

ImplementationImplementation

Designated infection control committee (consists of physicians, nurse managers, EVS, and hospital administration)◦In house training ◦Required attendance to initial training within

one month of implementation

Surveillance of compliance

Monitor hospital occurrence reports

DoDoActAct

PlanPlan

Data CollectionData Collection

Monitor environmental staff, healthcare workers, and patients for proper use of C. diff prevention protocol

Culture commonly touched areas (call light, bed rails, bedside tables, telephones) before and after cleaning◦ Culture same areas after using chlorine releasing sprays.

Monitor for adequate supply level and use

Data Collection cont.Data Collection cont.Collect results from educational surveys, pre- and

post- tests

Track infection readmission rates of patients with a hospital-acquired infection of C.diff

Examine treatment data

Monitor time required from first S/SX of C.diff infection Implementation of isolation/contact

DoDo

StudyStudy

PlanPlan

Performance MeasuresPerformance MeasuresGoals 0-6 months 6-12 months 12-18 months 18-25 months

Reduce hospital acquired C.Diff initial infections rates (HACD)

25% reduced 50% reduced 75% reduced 99.9% reduced

Biannual education survey score for all staff

80% pass 90% pass 100% pass 100% pass

Reduce readmission rate for HACD

25% reduced 50% reduced 75% reduced 99.9% reduced

Hand Hygiene and C. diff protocols

80% compliance 90% compliance 100% compliance

100% compliance

Evaluation/ Measuring ImprovementEvaluation/ Measuring ImprovementHave our goals been reached?

Monitor trends and whether implementations are meeting goals

If goals unmet - reexamine teaching methods, data collection methods…

Encourage input from staff on methods of improvement

Encourage unit goals - rewards for the best scores!

Data after Implementation of the Data after Implementation of the ProgramProgram

Weiss, Boisvert, Changnon, Duchesne,Habash, Lepage, Letourneau, Raty, Savoie, (2009)

ReferencesReferences Bertram, C. (2010). Stop C. Difficile: Education and hand washing save lives. Medical

Malpractice Law Blog. RZL, Inc. Retrieved May 20, 2010 from http://www.dcmedmalblog.com/patient-safety-stop-c-difficile-education-and-hand-washing-saves-lives.html

Centers for Disease Control and Prevention (2010), Guidelines for environmental infection control in healthcare facilities, retrieved May 25, 2010 from http://www.cdc.gov/ncidod/dhqup/id_Cdiff_excerpts.html

Centers for Disease Control and Prevention (2010), Information for healthcare providers, retrieved May 25, 2010 from http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html

Gould,D. (2009), Prevention and control of Clostridium difficile infection, Nursing Older People, 22(3), 29-37

MacLeod, N., Sadowski, C. (2010). Efficacy of cleaning products for C. difficile. Environmental strategies to reduce the spread of Clostridium difficile-associated diarrhea in geriatric rehabilitation. Canadian Family Physician. Vol. 56 pp. 417-423. Retreived May 25, 2010 from PubMed Database.

Muto, C., Blank, M., Marsh, J., Vergis, E., O’Leary, M., Shutt, K., Pasculle, A., Pokrywka, M., Garcia, J., Posey,K. Roberts, T., Potoski, B. Blank, G. Simmons, R., Veldkamp, P., Harrison, L. Paterson, D. (2007), Control of an outbreak of infection with the hypervirulent colostridium difficile bi strain in a university hospital using a comprehensive “bundle” approach, Clinical Infectious Diseases, 45, 1266-1273

Weiss, K., Boisvert, A., Chagnon, M., Duchesne, C., Habash, S., Lepage, Y., Letourneau, J., Raty, J., Savoie, M. (2009), Multipronged intervention strategy to control an outbreak of Clostridium difficile infection (cdi) and its impact on the rates of cdi from 2002-2007, Infection Control and Hospital Epidemiology, 30(2), 156-162