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

1. Infection Control for the Prevention of Clostridium difficile (C.diff) in the hospital Bobby Enriquez Monica Ferguson Darlene Lo Jeanne Wu Quality Improvement Project N607 Program Evaluation Summer 2010

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

3. 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. Clostridium Difficile

4. 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 Why is C.diff a problem?

5. 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 Clostridium Difficile

6. 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 Chain of Infection

7. Plan Do Act Study

8. 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

9. Fishbone Diagram: Spread of C. Diff. People Education Spread of C.diff Supplies Environment

10. 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

11. 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

12. 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

13. 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

14. 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.” Cause Analysis: Points of Weakness Bertram, C., 2010

15. 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 Cause Analysis: Points of Weakness

16. 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 Cause Analysis: Points of Weakness

17. 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 Lessons Learned at Home

18. 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) Lessons learned from Abroad

19. Plan Do Act Study

20. 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 (nurses, physicians, environmental staff, ancillary staff)

21. 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 everyone (nurses, physicians, environmental staff, ancillary staff) cont.

23. 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. Interventions for Nurses

24. 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 Interventions for Environmental Services (EVS)

25. Provide FAQ sheet on C.diff Interventions for Patient

26. 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 Implementation

27. Plan Do Act Study

28. 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

29. 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 Data Collection cont.

30. Plan Do Act Study

31. Performance Measures

32. 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! Evaluation/ Measuring Improvement

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

34. 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 hypervirulentcolostridiumdifficile 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 References