17 Steps to an Award-Winning C. Diff Reduction Program
Late last year, The Jewish Hospital-Mercy Health in Cincinnati received a first-place award in a multi-state competition for its efforts to reduce Clostridium difficile infections among inpatients. The award came from Anthem Blue Cross Blue Shield's Quality-In-Sights Hospital Incentive Program, which aims to improve the quality of healthcare provided in the hospital setting.
It was an award that recognized a few years and many hours of work by the staff at The Jewish Hospital. In 2009, the hospital's C. diff incidence rate was 25.27 per 10,000 patient days.
"Our patients on the average are older; we have a high number of Medicare/Medicaid-type patients," says Jenny Martin, RN, MSN, manager of quality for The Jewish Hospital. "We also have a lot of nursing homes in our communities as well. They're a high-risk population. When we started seeing our [C. diff] rates climb, that was alarming. We have a definite commitment to excellent patient care and quality, and that was a flag to us that we needed to do something immediately to improve our outcomes for our patients."
And that they did. By March 2010, the incidence rate was down to 21.1. By the summer of 2011, the rate had fallen to 3.08 per 10,000 patient days, almost half of the statewide incidence rate of 6.1 per 10,000 patient days.
To bring about the drastic reduction in incidence rate, the organization took a number of steps to identify problem areas and improvement opportunities. Here are 17 of the steps taken by The Jewish Hospital that helped reduce its C. diff rate and ultimately led to the award recognition.
1. Assemble a multidisciplinary task force. One of the first steps taken by the hospital was to assemble a task force focused on reducing C. diff. The team included Infection Preventionist Azalea Wedig, BS, CIC, physicians, an administrative liaison, environmental services personnel, members of the pharmacy and staff nurses from units identified with the higher incidence rates.
"At the beginning we met about every two weeks, then over time it became monthly," says Ms. Martin.
2. Perform literature review. "We did a literature review to see what was out there that would provide some ideas we could take," Ms. Martin says. "We didn't want to reinvent the wheel if we didn't have to."
3. Conduct risk assessment. The task force conducted a thorough risk assessment to identify the most significant issues.
"We came down to three main focuses — broad spectrum antibiotic use, environmental cleaning and standardization of our clinical care — and those became the three focuses for the task force," Ms. Martin says.
4. Develop environmental services action plan. Of the three focuses for the task force, the primary focus fell to environmental cleaning and services because of its historical role in contributing to the spread of C. diff.
"Based on the literature and the guidelines, keeping the environment clean was big," says Ms. Wedig. "We looked at things, such as how soon were suspected C. diff cases isolated and how often were curtains changed in rooms where patients had been discharged from C. diff isolation. We looked at the processes associated with cleaning the bathrooms. We observed use of non-dedicated isolation equipment and improper use of personal protective [equipment] as being contributing factors to a dirty environment. We looked at these and identified changes that were appropriate. These process changes had the most immediate and effective impact on our results."
5. Look at broad spectrum antibiotic use. The task force examined the 10 broad spectrum antibiotics used to treat patients, and the hospital's pharmacists determined it was critical for physicians not to injudiciously use antibiotics.
"Heightened awareness and monitoring of antibiotics resulted in the de-escalation of therapy," says Ms. Wedig. "We identified Imipenem and Cefepime with a higher incidence of hospital-acquired infection."
6. Analyze the standardization of clinical care. A C. diff protocol was developed. Based on this protocol, the medical staff empowered nursing to order the first C. diff test in the event a physician was unavailable to order the test. Isolation was initiated upon admission and ruling out was immediate.
7. Invest in technology. The Jewish Hospital purchased the Neogen AccuPoint HC real- time ATP cleaning, validation and tracking system which was used in patient rooms following an environmental service cleaning.
"We used this device, which tests for ATP (adenosine triphosphate) to see if there was bacterial residue left behind after cleaning," says Ms. Wedig. "We could then provide staff quick feedback until they learned, over time, to really do an effective job of cleaning the high-touch points in the room."
8. Change cleaning products and restrict equipment use. "In rooms housing patients with C. diff, the hospital changed its cleaning products to those most effective against C. diff spores," says Ms. Wedig. "Equipment, such as toilet scrubbers, were dedicated and discarded after use. This way we were not taking organisms out of the room."
9. Implement tracking and monitoring. The hospital stepped up its efforts in tracking data relevant to reducing C. diff, including the effectiveness in cleaning and killing C. diff spores through use of the Neogen system and how often curtains were changed between patients.
"So not only did we implement the changes but we monitored them and kept reeducating [on our improved processes] until we saw consistent changes implemented," Ms. Wedig says.
This practice continues on today, says Ms. Martin.
"We're continuing to monitor," she says. "We work to maintain consistency with the protocols and the standards we put in place with all of the departments."
10. Increased frequency of cleaning rooms with C. diff patients. A simple change, but one that played a role in reducing incidences, was increasing the frequency of cleaning the rooms with C. diff patients. The hospital doubled its bathroom cleaning rate, going from a single daily bathroom cleaning to cleaning twice daily.
11. Emphasize teamwork. Ms. Wedig says teamwork played a vital role in the improvement process, particularly between nurses/patient care assistants and the environmental services team.
"If environmental services was going to do its job appropriately, they had to clean everything; however, they weren't allowed to touch some of the patient's personal items," she says. "So we encouraged our PCAs and RNs to declutter the patient's environment, the over-the-bed table, the nightstand and areas around the sink. This would allow environmental services to come in and do a more efficient cleaning of each patient's room."
12. Changed practice for testing specimens for C. diff. The hospital saw patients coming into the facility with symptoms of C. diff, but when specimens from these patients were initially tested, the lab would send back negative results. Later, these patients would test positive for C. diff, says Ms. Wedig.
"We dug into C. diff testing methodology to discover that many false negatives occur if you do not get the specimen to the lab and test it in a very timely manner," she says. "The toxin you are testing for deteriorates very quickly, and if you don't get the test done quickly, you get a false negative."
This discovery was a big "ah-ha" for the task force, Ms. Wedig says. The team set out to educate the nursing staff members who collected specimens about the importance of delivering specimens to the lab in a timely fashion to ensure proper results.
"They couldn't sit at the nursing station until the runner came," Ms. Wedig says. "Stool had to be put on ice and delivered immediately"
These staff members were also educated on what an "appropriate specimen" meant.
"It's not a formed stool," she says. "It had to take the form of the container. A result is only as good as its specimen. If it was not diarrhea, then it wasn't an appropriate specimen."
Once the hospital changed its testing practices, the lab started to return more accurate and more positive results, she says. Ruling out a case of C. diff required isolation. Positive results required isolation and negative results were true negatives which would release the patient from isolation. This helped prevent the spread of the organism.
13. Monitoring and education of visitors. While the task force focused on training staff members on best practices for isolated patients and ensuring consistency in the performance of these practices, the team discovered another group of people who required attention and training: patients' families and visitors.
"They were coming in and not following the proper practices, and we were concerned that they were potentially contaminating other parts of the hospital or taking it home and contaminating their family members," says Ms. Wedig. "We had to do some education and provide feedback to visitors. Nurses had to be vigilant, watching what visitors were doing and stopping them if they were not gowning, gloving and washing their hands properly when they went in and out of the [patient's] room."
14. Changing gloving and hand hygiene practices. The Jewish Hospital changed its policies to require staff members to always wear gowns and gloves while providing care to isolated C. diff patients, in accordance with the SHEA-IDSA Compendium of Strategies to Prevent Healthcare-Associated Infections, says Ms. Wedig. The hospital also required hand hygiene be performed using soap and water and not alcohol gel.
15. Recognize efforts of the environmental services and other successful departments. The effort by the environmental services department, the area of initial focus for the overall initiative, to contribute to positive changes and reduction in the incidence rate did not go unnoticed.
"We saw a 50 percent reduction within the first six months of implementing the reduction plan, says Ms. Wedig. "Initial emphasis was initially given to cleaning the environment.”
To recognize these efforts, Ms. Wedig implemented a new annual infection prevention award called the "Hamsa Hand Infection Prevention" award. "In Hebrew numerology, the word 'hand' equals the number 'five,'" she says. "The fifth letter of the Hebrew alphabet signifies the name of God. With the Jewish belief in God as guardian and protector, the Hamsa Hand was adopted as a symbol of protection. The Hamsa Hand conveys a message of a sacred sign, putting a barrier between us and anything that might bring us harm."
The first award was given to the environmental services department (an ancillary department) and the unit that showed greatest improvement in measurable data.
"We are a Jewish hospital, so we adopted that [symbol]," she says. "I think giving the folks [in environmental services] the award made them feel proud of what they had accomplished. Ancillary departments don't directly generate a measurable and reportable rate; however, indirectly, their responsibilities impact departments that do generate data. Staff in these departments may not always understand the importance and impact of their services. This award recognizes both ancillary departments and units since they have to work as teams to succeed.”
16. Mandate real-time reporting. Since the incidence rate is now significantly lower and infection is not commonplace, infection control continues to report hospital-acquired infections to the floor manager immediately upon discovery.
"We report it to the manger so there's immediate feedback to the floor," says Ms. Wedig. "This is another way of sustaining [the low rate]. It also helps keep [staff members] aware that infections have not gone away. Real-time reporting is one of the elements of keeping the numbers down.
17. Celebrate the accomplishment. The Quality-In-Sights Hospital Incentive Program award was received at a leadership meeting, and task force team members were invited to that meeting.
"We really needed the positive recognition at that time," says Ms. Martin. "It meant so much to that staff that worked so hard and made so many changes and that positive recognition was at the heart of the award. It's a multi-state award and we're not always recognized within the city of Cincinnati. This made us look like and feel like the number one quality hospital within a five-state region."
Learn more about The Jewish Hospital – Mercy Health.
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