ABSTRACT

1. Implementation of Disposable Blood Pressure Cuffs as a Novel Approach to Reduce Fomite Transmission of Health-Care Associated Clostridium difficile Infection (CDI) in a Community Hospital Carolyn Fiutem, MT(ASCP), CLS(NCA), CIC1, Eileen Alexander, RN, BSN, MS, CIC2, Jane Khoury, PhD2,3, Paul Succop, PhD2, Stephen Kralovic, MD, MPH2,4 1Deaconess Hospital, Cincinnati, Ohio, 2University of Cincinnati, College of Medicine, 3Cincinnati Children’s Hospital Medical Center, 4Cincinnati VA Medical Center There are no financial disclosures by any members of this project. ABSTRACT ISSUE: CDI has garnered increased attention over the past several years. Current recommendations include contact precautions and hypochlorite disinfection of surfaces and equipment. Fomites have been implicated in health-care associated (HCA) CDI. Little research is available for blood pressure (BP) cuffs. PROJECT: Equipment purchases over the years resulted in a variety of reusable woven, nonwoven and disposable BP cuffs in inpatient and outpatient locations and inconsistent disinfection of cuffs. The Environmental Services Department was adept at hypochlorite disinfection of units due to other diarrheal outbreaks the prior year. The Nursing staff was adept at instituting contact precautions for all patients admitted with diarrhea. It was decided that the next logical step was a more rigorous application of “dedicated equipment” for contact precautions. At an institutional level, standardized and adaptive BP equipment was ordered and disposable BP cuffs were implemented in December 2004. Due to budget constraints, the institution ceased ordering the disposable cuffs in January 2006. The Infection Control Team discovered this when rates of CDI rose and we observed re-use of disposable cuffs and woven cuffs put back into service. Disposable cuffs were re-implemented in July 2006 and are now for single patient use only. This created a natural history experiment with two before and after periods for the intervention. CDI rates from January 2004 through June 2007 were analyzed. A Poisson model was used to evaluate the binary variable “intervention” with least squares mean estimates. The mathematical model is: cases/patient days (by month) = intervention. RESULTS: Predicted cases per month (X1000) = 1.63 without the disposable cuffs (p<.0001) and 0.76 with disposable cuffs (p< .0001). Patients are 53% less likely to have CDI with disposable BP cuffs (p=.001). LESSONS LEARNED: Fomites contribute to CDI. Disposable blood pressure cuffs and “dedicated equipment” yield a statistically significant reduction in HCA CDI. Collect and discard replaced equipment to prevent it from being put back into service, circumventing the original patient safety intent and cost benefit. This analysis reinforced the importance of formalizing results to validate both intervention and process. Medical and executive staff and front line managers gain comfort with the paradigm for improvement and cost-benefit analyses that cross unit specific line item budgets. ISSUE Clostridium difficile disease (CDI ) has garnered considerable attention over the past several years. Current recommendations include contact precautions and hypochlorite disinfection of surfaces and equipment. Fomites have been implicated in HCA CDI. Little research is available for blood pressure (BP) cuffs. PROJECT Deaconess Hospital is a small community hospital which serves an adult population. In spite of consistent cleaning protocols, hand hygiene, and isolation practices, the rates of CDI continued to rise. Equipment purchases over the years resulted in a variety of reusable woven, nonwoven and disposable BP cuffs in inpatient and outpatient locations and inconsistent-to-impossible disinfection of those cuffs. The Environmental Services Department was adept at hypochlorite disinfection of rooms due to other diarrheal outbreaks the prior year. The Nursing staff were adept at instituting contact precautions for all patients admitted with diarrhea. Following a cost-benefit analysis, it was decided that the next logical step was a more rigorous application of “dedicated equipment” for contact precautions, specifically BP cuffs. At an institutional level, standardized and adaptive BP equipment was ordered; a policy of disposable BP cuffs for every admission was implemented in December 2004 for four nursing units in the facility. At our facility, C. difficile testing can be initiated by the nursing staff to improve turn around times for identification of cases and the implementation of treatment, thus resulting in improved patient outcomes. The units ceased ordering the disposable cuffs in January 2006 in an attempt at cost containment. The Infection Control Team discovered this when rates of CDI rose and the resulting investigation revealed re-use of disposable cuffs and woven cuffs that had been put back into service. Disposable , single patient use BP cuffs for every admission were re-implemented in July 2006. This created a natural history experiment with two before and after periods for the intervention. Monthly CDI rates from January 2004 through June 2007 were analyzed. RESULTS Patients are 53% less likely to have CDI with disposable BP cuffs (p=.001). Fomites contribute to CDI; disposable BP cuffs, added to the arsenal of dedicated equipment, yield a statistically significant reduction in HCA CDI. A Poisson model was used to evaluate the binary variable “intervention” with least squares mean estimates. Poisson regression was chosen due to the low number of “count” data. The continuous dependent variable “rate” is regressed on the dichotomous independent variable “intervention.” (A repeated measures time series would have required either the same subjects/patients over time or the use of “unit” as subject, and a greater number of nursing units to achieve adequate power.) The mathematical model is: cases/patient days (by month) = intervention. CDI rates from January 2004 through June 2007 were analyzed. The rate of incident CDI by unit and month ranged from 0 – 14.60 with a mean of 1.11. Predicted cases per month (X1000) = 1.63 without the disposable cuffs (p<.0001) and 0.76 with disposable cuffs (p< .0001). Data were analyzed using Proc Genmod SAS/STAT. SAS Institute Inc., Cary, NC 2003 • LESSONS LEARNED • Fomites contribute to CDI. Disposable blood pressure cuffs yield a statistically significant reduction in HCA CDI. • This suggests that “dedicated equipment” should be clearly defined and rigorously adhered to by all staff to successfully implement contact precautions for the prevention of CDI. • Collect and discard replaced equipment to prevent it from being put back into service, circumventing the original patient safety intent and cost benefit. • This analysis reinforced the importance of formalizing results to validate both intervention and process. Medical and executive staff and front line managers gain comfort with the paradigm for improvement and cost-benefit analyses that cross unit specific line item budgets. The 2005 cost savings due to CDI reduction were calculated and exceeded those of the initial cost analysis. • The limitations of this project were that the trial was not randomized and other risk factors were not recorded or analyzed. This trial cannot be generalized to other populations. • Future randomized, microbiological & clinical studies of fomite transmission by “common equipment” are warranted. For additional information & references, contact fiuca@deaconess-cinti.com