Clinical Guided Project - PresentationNUR 440: Dr. Deborah Garrison and Nancy BucherBy: Krystal DeSantis, Lucy George & Melinda Gillies

Due: November 28, 20121

Infection Control: Clostridium difficile

Clinical Issue

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Clostridium Difficile

40% affected in hospital setting

Surpasses MRSA infections

Infection Control

(Grossman & Mager, 2010, p. 155) – 40% affected

(Page, 2011, p.8) - MRSA

Evolution of Clostridium difficile

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1930’s: Identification

1970’s: Health issues

1978: “Infectious cause of antibiotic-associated diarrhea”

(Keske & Letizia, 2010, p. 329)

Strains of Clostridium difficile

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Toxin A

Toxin B

NAPI

(Grossman & Mager, 2010, p. 155) – Toxin A and Toxin B

(Evans, 2012, p. 39) - NAPI

Mode of Transmission

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Fecal-oral route

Issue at hand

Objects

(Pelleschi, 2008, p. 28) - transmission

(Keske & Letizia, 2010, p. 330) - objects

Individual Risk Factors

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Antibiotic Use

Advanced Age

Surgery

Chemotherapy

Severe illnesses

Decreased stomach acidity(Pelleschi, 2008, p. 29)

Signs and Symptoms

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Ranging from mild to severe

Systemic Complications

(Pelleschi, 2008, p. 29-30)

Development of Clostridium difficile

8 (Pelleschi, 2008, p. 28)

Example of Clostridium difficile

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Cancer patient with Clostridium difficile infection

Chemotherapy

Risk factors

Patient History

Nursing Role (Winkeljohn, 2011, p. 215-216)

Quantitative Data: Clostridium difficile

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Age group affected

Amount of individuals affected

Costs for treatment

Mortality rate

(CDC, 2012, p. 157-158)

HAI PreventionPA Dept. of Health requires all hospitals to

report HAIs within 24 hours of occurrence

PADOH supports a prevention collaborative between hospitals in southeastern PA to reduce the occurrence of CDIs

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Healthcare-Associated Infections (HAI) Report: Q+A. (2011).Retrieved from http://www.portal.state.pa.us/portal/server.pt/community/healthcare_associated_infections/14234

Infection Control & Prevention

An estimated 94% of CDIs are potentially avoidable through responsible antibiotic use and the prevention of horizontal transmission (Cohen et al., 2010)

Hospitals instituting infection control and prevention programs were successful in reducing CDI rates by 20% over a period of 21 months. (CDC, 2012)

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Cohen S et al. Infect Control Hosp Epidemiology 2010; 31(5), 431-455.CDC (2012). Vital signs: 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

13Cohen S et al. Infect Control Hosp Epidemiology, 2010; 31(5), 431-455.

Components of an Infection Control & Prevention Plan

An early detection systemInterruption of person-to-person spreadElimination of environmental

contamination Education, and Monitoring

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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

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Cohen S et al. Infect Control Hosp Epidemiology, 2010; 31(5), 431-455. 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)

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Sethi AK et al. Infect Control Hosp Epidemiology; 31(1), 21-27. C. Young, personal communication, October 16, 2012

Justification for Extending Contact Isolation

17 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/restrictions

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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.

19 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.

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CDC (2012). Vital signs: Preventing Clostridium difficile infections. Morbidity & Mortality Weekly Report – MMWR, 61(9), pp. 157-162. Hacek, D et al. Am J Infect 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.”

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Orenstein R et al. Infect Control Hosp Epidemiology 2011;32(11), 1137-9.

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

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Allen S et al. Dim Crit Care Nurs 2012, 31(5), 290-294. Retrieved from CINAHL database. Carboneau C et al. J Healthc Qual 2010 ; 34(4) 61-70.

Impact of Education 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. difficile

23 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 discharge

24 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

Effectiveness of environmental cleaning by housekeeping

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Guh, A., & Carling, P. (2010). Options for evaluating environmental cleaning. Retrieved from the Centers for Disease Control and Prevention website: 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 staff will also be assessed.

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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

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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: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf

Quantum Leadership Theory

Shared decision makingCoachingMentoring

Employee empowerment

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Successful and Effective Leader

Constructs effective teams

Shared vision

Believes every employee is unique and important

(Ercetin and kamaci, 2008)

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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)

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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 possible

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Implementation of an Infection Control Plan

Establish infection control committeeMultidisciplinary teamOne member trained in infection control, responsible

for education, surveillance and trackingPerform risk assessment to guide plan implementation Investigate and analyze clusters of Clostridium difficile

infectionData collected and analyzed for infection and manner

of spread Information kept in computer and manualHope to decrease to decrease CDI within six months

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Proposed CDI Plan

Hold in-service for all medical staffEducate staff regarding what C.diff is and the

mode of infection transmissionExplain importance of rapid identification to place

patient in isolationImportance of contact precautions explained

Educate staff on personal protective equipment (PPE)

PPE includes use of gloves and gownsEducate staff on how to put on and remove PPE

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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 committee

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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 understanding

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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 checksMonitor use of soap and waterUse skill validation check listUse check list as a tool to counsel staff as needed

Staff encouraged to ask each other about hand washing

(Pyrek & Orenstein, 2010)

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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 bathroom

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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 required

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ConclusionNot one strategy alone can eradicate or lower

CDICombination of antibiotic control, good hygiene

and environmental cleaningHold staff accountable with help of

management and infection control committeeRegular education of staff is an important

driving force behind lowering CDI ratesHave staff demonstrate competencyMost important factor behind implementing

change is patient safety

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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.

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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 environmental cleaning. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf

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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_associated_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.

Orenstein, R., Aronhalt, K., & McManus, J. (2011). A targeted strategy to wipe out Clostridium difficile. Infection Control and Hospital Epidemiology, 32(11), 1137-9. Retrieved from CINAHL database.

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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//www.infectioncontroltoday.com/

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: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf

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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.215-21

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