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