Infection Control for the Prevention of Clostridium difficile (C.diff) in the hospital

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Infection Control for the Prevention of
Clostridium difficile (C.diff) in the hospital
Quality Improvement Project N607 Program
Evaluation Summer 2010
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Area for Quality Improvement

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

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Clostridium 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.

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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

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Clostridium Difficile

• Signs/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

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Chain of Infection

• Infected 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

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Plan
Do
Act
Study
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Flowchart Key
Patient suspected of C. diff?
Obtain stool sample
Initiate C. diff protocol
Yes
Start/End
Decision
No
Send to laboratory STAT
Action
Yes
Utilize Standard Precautions
Flow
Results positive for C. diff?
No
Yes
Discontinuation of C. diff protocol?
No
Limit indiscriminate use of antibiotics
Contact precautions
Environmental cleaning
Continue C. diff protocol
Reassessment
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Fishbone Diagram Spread of C. Diff.
People
Education
Spread of C.diff
Supplies
Environment
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Education
Hospital personnel not updated on C. diff
protocol
Patient and visitors unaware of C.diff prevention
measures

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

Improper hand hygiene
Spread of C. diff spores
Epidemiology not understood
Noncompliance to C. diff protocol
Spread of C. diff
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People
Nurses
High patient load
Hospital staff
Lack of time
Stress

• unaware of C.diff protocol
• noncompliance

Non-compliance with contact precaution protocol
Improper hand hygiene
Shortage of supplies
Cleaning staff
Visitors
Inadequate cleaning
unaware of C. diff protocol

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

Patient
Immunocompromised.
Spread of C. diff
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Spread of C. diff
Supply room location inconvenient
supplies and dedicated equipment not stocked in
patient rooms.
Improper cleaning
C.Diff spores left on surfaces
Lack of single rooms
greater likelihood of infection
next patient or staff touches spores
Sink location inconvenient
staff spread spores to immuno-compromised patient
Staff less likely to wash hands with soap and
water
immunocompromised patient is assigned room and
becomes infected
Environment
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Spread of C. diff
Lack of patient specific equipment
spores remain on community equipment
spores get passed to other patients
PPE equipment not replenished

• gloves
• gowns

Improper cleaning solution
spores remain on common areas
hospital staff come in contact with spores
Supplies
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Cause Analysis Points of Weakness

• Education
• A study at one hospital found that 39 of
  resident physicians and other medical personnel
  didnt know that C. diff spores could be
  transmitted from patient to patient on
  equipment.

Bertram, C., 2010
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Cause Analysis Points of Weakness

• People
• 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

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Cause 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

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Lessons Learned at Home

• University 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

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Lessons 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)

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Plan
Do
Act
Study
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Interventions for everyone (nurses, physicians,
environmental staff, ancillary 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

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Interventions for everyone (nurses, physicians,
environmental 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 patients door
• Epidemiology
• Spore formation and its spread.

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Interventions for Nurses

• Education 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.

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Interventions for Environmental 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 pts room)
• Special training on C. diff infection
• Use of chlorine-releasing agents

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Interventions for Patient

• Provide FAQ sheet on C.diff

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Implementation

• 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

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Plan
Do
Act
Study
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Data 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

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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

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Plan
Do
Act
Study
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Performance Measures
Goals 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
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Evaluation/ Measuring Improvement

• Have 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!

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Data after Implementation of the Program
Weiss, Boisvert, Changnon, Duchesne,Habash,
Lepage, Letourneau, Raty, Savoie, (2009)
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References

• 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.h
  tml
• 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_C
  diff_excerpts.html
• Centers for Disease Control and Prevention
  (2010), Information for healthcare providers,
  retrieved May 25, 2010 from http//www.cdc.gov/nci
  dod/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.,
  OLeary, 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