Evolution of Clostridium difficile 1930’s: Identification 1970’s: Health issues 1978: “Infectious cause of antibiotic-associated diarrhea” (Keske & Letizia, 2010, p. 329)3
Strains of Clostridium difficile Toxin A Toxin B NAPI (Grossman & Mager, 2010, p. 155) – Toxin A and Toxin B (Evans, 2012, p. 39) - NAPI4
Mode of Transmission Fecal-oral route Issue at hand Objects (Pelleschi, 2008, p. 28) - transmission (Keske & Letizia, 2010, p. 330) - objects5
Individual Risk Factors Antibiotic Use Advanced Age Surgery Chemotherapy Severe illnesses (Pelleschi, 2008, p. 29) Decreased stomach acidity6
Signs and Symptoms Ranging from mild to severe Systemic Complications (Pelleschi, 2008, p. 29-30)7
Development of Clostridium difficile8 (Pelleschi, 2008, p. 28)
Example of Clostridium difficile Cancer patient with Clostridium difficile infection Chemotherapy Risk factors Patient History Nursing Role (Winkeljohn, 2011, p. 215-9 216)
Quantitative Data: Clostridium difficile Age group affected Amount of individuals affected Costs for treatment Mortality rate (CDC, 2012, p. 157-158)10
Infection Control & Prevention Hospitals instituting infection control and prevention programs were successful in reducing CDI rates by 20% over a period of 21 months. (CDC, 2012) An estimated 94% of CDIs are potentially avoidable through responsible antibiotic use and the prevention of horizontal transmission (Cohen et al., 2010) Cohen S et al. Infect Control Hosp Epidemiology 2010; 31(5), 431-455.CDC (2012). Vital signs:11 Preventing Clostridium difficile infections. Morbidity & Mortality Weekly Report – MMWR, 61(9), pp. 157-162.
Antibiotic Stewardship Reduce overuse and inappropriate selection of antibiotics Shorter duration of treatment Cohen S et al. Infect Control Hosp Epidemiology, 2010; 31(5), 431-12 455.
Components of an Infection Control & Prevention Plan An early detection system Interruption of person-to-person spread Elimination of environmental contamination Education, and Monitoring13
Early Detection Increasing the number of diarrheal stool tested for C. difficile Recognizing the limits of toxin A/B immunoassay Laboratory-based alert system for immediate notification of positive test results Nurse-driven protocol for stool testing Cohen S et al. Infect Control Hosp Epidemiology, 2010; 31(5), 431-455.14 Christine Young, personal communication, October 16, 2012
Interruption of Horizontal Transmission Place all tested patients on preemptive contact precautions/isolation for pending confirmation of CDI Extend use of contact precautions/isolation beyond duration of diarrhea (e.g., until discharge and if readmitted within 6 weeks) Sethi AK et al. Infect Control Hosp Epidemiology; 31(1), 21-27.15 C. Young, personal communication, October 16, 2012
Justification for Extending Contact Isolation16 Bobulsky G et al. Clin Infect Dis 2008;46:447-50.
Interruption of Horizontal Transmission Implement soap and water for hand hygiene Hand hygiene for patients Personal protective equipment Use of dedicated non- critical medical equipment Visitor requirement/restrictions17
Elimination of Environmental Contamination C. difficile spores can remain on surfaces for long periods of time and are resistant to commonly used disinfectants. Transmission of C. difficile from patient-to-patient is directly proportional to the amount of environmental contamination.18 Weber D et al. Am J Infect Control 2010; 38(5 Suppl 1):S25-33.
Environmental Cleaning Reduces the load of C. difficile spores within the environment preventing the transmission of the disease to uninfected patients. Recommendations include routine daily isolation cleaning using a low-level disinfectant. Terminal cleaning with a 10% chlorine-based product: results in a 48% reduction in the prevalence density of C. difficile. CDC (2012). Vital signs: Preventing Clostridium difficile infections. Morbidity & Mortality Weekly Report – MMWR, 61(9), pp. 157-162. Hacek, D et al. Am J Infect19 Control 2010; 38(5), 350-3.
Supplemental Measures for High –Risk Units High loads of C. difficile spores or outbreaks of CDI will necessitate daily cleaning with Clorox ultra-germicidal bleach wipes containing 6.15 percent sodium hypochlorite. Orenstein (2011) showed daily use of these wipes on a high-risk unit “effectively reduced the acquisition rates of CDI by one-third and time between cases from 8 to 80 days.” Orenstein R et al. Infect Control Hosp Epidemiology 2011;32(11), 1137-9.20
Education of Hospital Personnel Annual education regarding CDI prevention with special attention to appropriate hand hygiene and contact isolation precautions Re-education of staff if the hospital experiences an outbreak Allen and Nones-Cronin (2012) report an increase in staff members’ compliance with infection control measures after educational intervention Allen S et al. Dim Crit Care Nurs 2012, 31(5), 290-294. Retrieved from CINAHL21 database. Carboneau C et al. J Healthc Qual 2010 ; 34(4) 61-70.
Impact of Educational Intervention Important in overcoming barriers to effective implementation Inconsistent cleaning of high-touch surfaces (i.e. bedrails, telephones, call buttons, door knobs, toilet seats, and bedside tables) Educational intervention for housekeeping staff resulted in a 70% reduction in positive cultures for C. difficile22 Eckstein B et al. BMC Infect Dis 2007; 7, 61.
Education of Patients & Visitors Basic facts Infection Control Measures Special discharge teaching – patients may be at an increased risk for developing CDIs up to 3 months after hospital discharge23 Murphy C et al. Infect Control Hosp Epidemiology 2010; 33(1), 20-28.
Monitoring Determines the success of the infection control and prevention program Ensures the continual use of best practices by hospital staff and helps to determine if interventions are positively impacting patient outcomes Guh, A., & Carling, P. (2010). Options for evaluating environmental cleaning. Retrieved from the Centers for Disease Control and Prevention website:24 http://www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf
Monitoring (continued) Track monthly compliance with infection control measures including hand hygiene and PPE use Track number of CDIs per 1,000 patient days Effectiveness of environmental cleaning by housekeeping staff25
Cost Savings Centers for Medicare and Medicaid Services (CMS) will reduce or eliminate payment for hospital-acquired CDI. Hospitals responsible for cost of treatment estimated at $35.7 billion to $45 billion for in-patient services Potential annual savings due to infection control measures range from $5.7 billion to $31.5 billion Scott, R. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved from the Centers for Disease Control and Prevention website:26 http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Quantum Leadership Theory Shared decision making Coaching Mentoring Employee empowerment27
Successful and Effective Leader Constructs effective teams Shared vision Believes every employee is unique and important (Ercetin and kamaci, 2008)28
Communication Necessary for successful decision making and implementing change Active listening essential Leader must be able to acknowledge and respond to staff emotions (Porter-O’Grady & Malloch, 2011)29
Communication (continued) Important to have effective plan of early communication to implement a change Everyone affected by proposed plan of change should be involved Imperative to provide as much information as possible30
Implementation of an Infection Control Plan Establish infection control committee Multidisciplinary team One member trained in infection control, responsible for education, surveillance and tracking Perform risk assessment to guide plan implementation Investigate and analyze clusters of Clostridium difficile infection Data collected and analyzed for infection and manner of spread Information kept in computer and manual31 Hope to decrease to decrease CDI within six months
Proposed CDI Plan Hold in-service for all medical staff Educate staff regarding what C.diff is and the mode of infection transmission Explain importance of rapid identification to place patient in isolation Precautions explained on the use of personal protective equipment (PPE) Staff to be taught proper procedure to put on and remove PPE Staff to be taught how to dispose of PPE appropriately32
Implementation of Contact Precautions Protocols Staff expected to demonstrate proper way to put on and remove PPE Point person assigned to units to assure PPE readily available Point person to ensure staff compliance Point person will keep surveillance forms and send to infection control committee33
Hand Hygiene Education Critical element of plan Essential to eliminating CDI outbreaks Only acceptable method is soap and water Quizzes given to staff to ensure understanding34
Implementation of Hand Hygiene Protocols Hands to be washed for at least 15 seconds before and after entering a patient’s room Point person assigned to perform hand washing checks Monitor use of soap and water Use skill validation check list Use check list as a tool to counsel staff as needed Staff encouraged to ask each other about hand washing35
Environmental Cleaning Transmission of contaminated patient surfaces and medical equipment is significant if not cleaned properly Important to educate housekeeping on cleaning high touch areas to eliminate spread of infection Daily cleaning of high touch areas vital Educate staff to use 10% chlorine bleach solution or bleach wipes. Educate importance of cleaning bathrooms twice a day Educate importance of dedicated cleaning equipment to be kept in patient’s bathroom36
Implementation of Environmental Cleaning Hygiene Environmental manager in charge of monitoring appropriate chemicals being used Environmental manager will utilize Digiglo light to evaluate proper disinfecting Digiglo will be used to decide if further education is needed regarding cleaning is required37
Conclusion Not one strategy alone can eradicate or lower CDI Combination of antibiotic control, good hygiene and environmental cleaning Hold staff accountable with help of management and infection control committee Regular education of staff is an important driving force behind lowering CDI rates Have staff demonstrate competency Most important factor behind implementing change is patient safety38
References Allen, S., & Nones-Cronin, S. (2012). Improving staff compliance with isolation precautions through use of an educational intervention and behavioral contract. Dimensions of Critical Care Nursing, 31(5), 290- 294. Retrieved from CINAHL database. Bobulsky, G., Al Nassir, W., & Riggs, M. (2008). Clostridium difficile skin contamination in patients with C. difficile-associated disease. Clinical Infectious Diseases, 46, 447–450. Carboneau, C., Benge, E., Mary T. Jaco, M., & Robinson, M. (2010). A lean six sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%. Journal for Healthcare Quality, 34(4) 61-70. Retrieved from CINAHL database. Cohen, S., Gerding, D., Johnson, S., Kelly, C., Loo, V., McDonald, L., Pepin, J., & Wilcox, M.(2010). Clinical practice guidelines for C. difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. Infection Control and Hospital Epidemiology, 31(5), 431-455. Retrieved from CINAHL database.39
References (continued) Eckstein B., Adams, D., Eckstein, E., Rao, A., Sethi, A., Yadavalli, G., & Donskey, C. (2007). Reduction of Clostridium Difficile and vancomycin- resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BioMed Central Infectious Diseases, 7, 61. Retrieved from CINAHL database. Ercetin, S., & Kamaci, M., (2008). Quantum Leadership Paradigm. World Applied Sciences Journal, 3(6), 865-868. Retrieved from http://www.idosi.org/wasj/wasj3(6)/1.pdf Evans, G. (2012). Time to put the gloves on: C. diff patients death hit a historic high. Hospital Infection Control & Prevention, 39(4), pp. 37-42. Retrieved from CINAHL EBSCO Host database. Grossman, S. & Mager, D. (2010). Clostridium difficile: Implications for nursing. MEDSURG Nursing, 19(3), pp. 155-158. Retrieved from CINAHL EBSCO Host database. Guh, A., & Carling, P. (2010). Options for evaluating environmental40 cleaning. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-
References (continued) Hacek, D., Ogle, A., Fisher, A., Robicsek, A., Peterson, L. (2010). Significant impact of terminal room cleaning with bleach on reducing nosocomial Clostridium difficile. American Journal of Infection Control, 38(5), 350-3. Healthcare-Associated Infections (HAI) Report: Q+A. (2011). Retrieved from http://www.portal.state.pa.us/portal/server.pt/community/healthcare_ass ociated_infections/14234 Keske L. A. & Letizia, M. (2010). Clostridium difficile infection: Essential information for nurses. MEDSURG Nursing, 19(6), pp. 329-333. Retrieved from CINAHL EBSCO Host database. Murphy, C., Avery, T., Dubberke, E., & Huang, S. (2012). Frequent hospital readmissions for Clostridium difﬁcile infection and the impact on estimates of hospital-associated C. difﬁcile burden. Infection Control and Hospital Epidemiology, 33(1), 20-28. Retrieved from CINAHL database.41 Orenstein, R., Aronhalt, K., & McManus, J. (2011). A targeted strategy to wipe out Clostridium difficile. Infection Control and Hospital
References (continued) Page, S. (2011). C. difficile surpasses MRSA as leading cause of nosocomial infections in community hospitals. New Hampshire Nursing News, 35(1), p. 8. Retrieved from CINAHL EBSCO Host database. Pelleschi, M. E. (2008). Clostridium difficile – Associated Disease: Diagnosis, prevention, treatment and nursing care. Critical Care Nurse, 28(1), pp. 27-36. Retrieved from CINAHL EBSCO Host database. Porter-O’Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing innovation, transforming healthcare. Sudbury, MA: Jones & Bartlett Learning. Pyrek, K., & Orenstein, R., (2010). Cleaning Intervention Cuts C. difficile Acquisition Rates by One-Third. Retrieved fromhttp://www.infectioncontroltoday.com/s.aspx?exp=1&u=http%3A//w ww.infectioncontroltoday.com/ Scott, R. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved42 from the Centers for Disease Control and Prevention website: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
References (continued) Sethi, A., Al-Nassir, W., Nerandzic, M., Bobulsky, G., & Donskey, C. (2010). Persistence of skin contamination and environmental shedding of C. difficile during and after treatment of C. difficile infection. Infection Control and Hospital Epidemiology, 31(1), 21-27. Weber, D., Rutala, W., Miller, M., Huslage, K., & Sickbert-Bennett, E. (2010). Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. American Journal of Infection Control, 38(5 Suppl 1):S25-33. Retrieved from CINAHL database. 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 to 2007. Infection Control & Hospital Epidemiology, 30(2), 156-162. Winkeljohn, D. (2011). Clostridium difficile infection in patients with cancer. Clinical Journal of Oncology Nursing, 15(2), pp. 215-217. doi:10.1188/11.CJON.215-2143
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