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Infection Control:           Clostridium difficile           Clinical Guided Project - Presentation    NUR 440: Dr. Debora...
Clinical Issue     Clostridium Difficile     40% affected in hospital setting     Surpasses MRSA infections     Infect...
Evolution of Clostridium difficile     1930’s: Identification     1970’s: Health issues     1978: “Infectious cause of ...
Strains of Clostridium difficile     Toxin A     Toxin B     NAPI    (Grossman & Mager, 2010, p. 155) – Toxin A and Tox...
Mode of Transmission     Fecal-oral route     Issue at hand     Objects    (Pelleschi, 2008, p. 28) - transmission    (...
Individual Risk Factors     Antibiotic Use     Advanced Age     Surgery     Chemotherapy     Severe illnesses        ...
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 fact...
Quantitative Data: Clostridium                  difficile      Age group affected      Amount of individuals affected   ...
Infection Control & Prevention      Hospitals instituting infection control and      prevention programs were successful ...
Antibiotic Stewardship      Reduce overuse and inappropriate selection of      antibiotics      Shorter duration of trea...
Components of an Infection          Control & Prevention Plan      An early detection system      Interruption of person...
Early Detection      Increasing the number of       diarrheal stool tested for C.       difficile      Recognizing the l...
Interruption of Horizontal                    Transmission      Place all tested patients on       preemptive contact    ...
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       ...
Elimination of Environmental                  Contamination      C. difficile spores can remain on surfaces for long     ...
Environmental Cleaning      Reduces the load of C. difficile spores within the       environment preventing the transmiss...
Supplemental Measures for High             –Risk Units      High loads of C. difficile spores or outbreaks of      CDI wi...
Education of Hospital Personnel      Annual education regarding CDI prevention with       special attention to appropriat...
Impact of Educational                  Intervention      Important in overcoming barriers to effective      implementatio...
Education of Patients & Visitors      Basic facts      Infection Control Measures      Special discharge teaching – pat...
Monitoring      Determines the success of the infection      control and prevention program      Ensures the continual u...
Monitoring (continued)     Track monthly compliance with infection control     measures including hand hygiene and PPE us...
Cost Savings      Centers for Medicare and Medicaid Services (CMS)       will reduce or eliminate payment for hospital-ac...
Quantum Leadership Theory      Shared decision making      Coaching      Mentoring      Employee empowerment27
Successful and Effective Leader      Constructs effective teams      Shared vision      Believes every employee is uniq...
Communication      Necessary for successful decision making and       implementing change      Active listening essentia...
Communication (continued)      Important to have effective plan of early      communication to implement a change      E...
Implementation of an Infection               Control Plan      Establish infection control committee        Multidiscipl...
Proposed CDI Plan      Hold in-service for all medical staff        Educate staff regarding what C.diff is and the mode ...
Implementation of Contact            Precautions Protocols      Staff expected to demonstrate proper way to put      on a...
Hand Hygiene Education      Critical element of plan      Essential to eliminating CDI      outbreaks      Only accepta...
Implementation of Hand Hygiene               Protocols      Hands to be washed for at least 15 seconds before      and af...
Environmental Cleaning      Transmission of contaminated patient surfaces and      medical equipment is significant if no...
Implementation of Environmental           Cleaning Hygiene      Environmental manager in charge of monitoring      approp...
Conclusion      Not one strategy alone can eradicate or lower CDI        Combination of antibiotic control, good hygiene...
References      Allen, S., & Nones-Cronin, S. (2012). Improving staff compliance with       isolation precautions through...
References (continued)      Eckstein B., Adams, D., Eckstein, E., Rao, A., Sethi, A., Yadavalli, G., &       Donskey, C. ...
References (continued)      Hacek, D., Ogle, A., Fisher, A., Robicsek, A., Peterson, L. (2010).       Significant impact ...
References (continued)      Page, S. (2011). C. difficile surpasses MRSA as leading cause of       nosocomial infections ...
References (continued)      Sethi, A., Al-Nassir, W., Nerandzic, M., Bobulsky, G., & Donskey, C.       (2010). Persistenc...
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  1. 1. Infection Control: Clostridium difficile Clinical Guided Project - Presentation NUR 440: Dr. Deborah Garrison and Nancy Bucher By: Krystal DeSantis, Lucy George & Melinda Gillies1 Due: November 28, 2012
  2. 2. Clinical Issue  Clostridium Difficile  40% affected in hospital setting  Surpasses MRSA infections  Infection Control (Grossman & Mager, 2010, p. 155) – 40% affected (Page, 2011, p.8) - MRSA2
  3. 3. Evolution of Clostridium difficile  1930’s: Identification  1970’s: Health issues  1978: “Infectious cause of antibiotic-associated diarrhea” (Keske & Letizia, 2010, p. 329)3
  4. 4. Strains of Clostridium difficile  Toxin A  Toxin B  NAPI (Grossman & Mager, 2010, p. 155) – Toxin A and Toxin B (Evans, 2012, p. 39) - NAPI4
  5. 5. Mode of Transmission  Fecal-oral route  Issue at hand  Objects (Pelleschi, 2008, p. 28) - transmission (Keske & Letizia, 2010, p. 330) - objects5
  6. 6. Individual Risk Factors  Antibiotic Use  Advanced Age  Surgery  Chemotherapy  Severe illnesses (Pelleschi, 2008, p. 29)  Decreased stomach acidity6
  7. 7. Signs and Symptoms  Ranging from mild to severe  Systemic Complications (Pelleschi, 2008, p. 29-30)7
  8. 8. Development of Clostridium difficile8 (Pelleschi, 2008, p. 28)
  9. 9. Example of Clostridium difficile  Cancer patient with Clostridium difficile infection  Chemotherapy  Risk factors  Patient History  Nursing Role (Winkeljohn, 2011, p. 215-9 216)
  10. 10. Quantitative Data: Clostridium difficile  Age group affected  Amount of individuals affected  Costs for treatment  Mortality rate (CDC, 2012, p. 157-158)10
  11. 11. 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.
  12. 12. 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.
  13. 13. Components of an Infection Control & Prevention Plan  An early detection system  Interruption of person-to-person spread  Elimination of environmental contamination  Education, and  Monitoring13
  14. 14. 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
  15. 15. 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
  16. 16. Justification for Extending Contact Isolation16 Bobulsky G et al. Clin Infect Dis 2008;46:447-50.
  17. 17. 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
  18. 18. 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.
  19. 19. 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.
  20. 20. 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
  21. 21. 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.
  22. 22. 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.
  23. 23. 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.
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. Quantum Leadership Theory  Shared decision making  Coaching  Mentoring  Employee empowerment27
  28. 28. Successful and Effective Leader  Constructs effective teams  Shared vision  Believes every employee is unique and important (Ercetin and kamaci, 2008)28
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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-
  41. 41. 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
  42. 42. 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
  43. 43. 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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