Infection Control Today

OCT 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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34 ICT October 2018 www.infectioncontroltoday.com C lostridium difficile infection (CDI) prolongs hospital stays, increase costs and can be life threatening. Our intensive care units' CDI rate remained high despite implementing environmental reduction strategies. Following a root cause analysis identifying needed protocol changes, our facility rates decreased by 88 percent and have had only one hospital onset (HO) CDI in more than 100 days. A literature review was conducted to determine best practice for CDI reduction in acute-care facilities. The evidence discussed several multidisciplinary approaches/strategies, including a few we already had in place. Spores of C. diffcile may persist on surfaces for years and remain a source of environmental contam- ination and infection. Our environmental procedures had been altered by adding a sporicidal cleanser/disinfectant in December 2015. Several months later, in September 2016, ultraviolet (UV) disinfection of rooms following occupation by CDI isolation patients began. The response to these strategies was good, but we knew we could do better, so increased protocol changes were needed to reach our target of zero. An analysis of current practices identifed several areas for improvement including communication between staff, decisions for next steps when patients were experiencing diarrhea, education concerning handling of CDI specimens and patient bathing practices. For bedside shift report, staff used a checklist which listed indicators for healthcare-associated infections (HAIs), including "are they having diarrhea?" and "for how many days?" specifc for CDI. This increased communication during the bedside shift change and prompted discussion of the patients CDI status and current treatment in the handoff. Standard protocol was to isolate patients as soon as CDI was suspected until the cause of diarrhea was identifed. We also include the patient in this discussion at the bedside. A Bundled Approach to Clostridium diffcile Infection Reduction In March 2017, a C. diff decision tree was created to use if a patient was having loose stools and staff suspected CDI. The tree identifed seven patient risk factors including: patient age, recent hospitalizations, antibiotic or proton pump inhibitor use, chemotherapy, history of CDI, HIV, infammatory bowel disease or cancer, stools characteristic of CDI, elevated WBC, fever, cramping or abdominal pain. The decision tree guides staff through a Q&A format and leads to "yes" or "no" branches. If the patient has identifed risk factors the "yes" path will cover the three days post-admission. Nurses were empowered to order a C. diff test and place the patient on precautions if they felt the patient met criteria in the frst three days of admission. From day four post-admission, the tree had directions insuring those tested met actual criteria and asked about laxatives or tube feedings, and how many loose stools within a 24-hour period. These measures helped avoid identifying colonized patients rather than only those with an active infection. During the same period, the staf f received additional education on specimen collection. The new protocol included that only specimens that mold to the shape of the container would be eligible for testing. The lab was educated to reject any specimens sent that did not meet this criterion or any specimens from patients that had been tested within the last seven days. We also switched to a two-step A-B toxin testing method. Our analysis also uncovered there was room for improvement with patient bathing practices also. APIC recommends showering or bed baths for patients with CDI. Studies show antimicrobial CHG soap kills the vegetative C. diffcile cells, and soap and water rinsing remove the spores. The ICUs had been using various bathing methods. Staff had had the option of using 2 percent CHG wipes or, for those preferring to administer a real bath, a 2 percent CHG which was diluted in a basin of water. We wanted to combine best practice recommendations while simplifying strategies. We discontinued the use of both the wipes and the 2 percent CHG and instituted a standardized bathing protocol. Starting in June 2017, every patient was bathed daily using undiluted HIBICLENS 4 percent CHG foam. Implementation included extensive education on the bathing change provided by product representatives. Staff on all shifts received in-servicing, which was documented on sign in sheets. Daily patient bathing was documented, and compliance was monitored using the electronic medical record (EMR). Early strategies had yielded only modest decreases in CDI rates, so we were challenged to examine our bundle components and analyze current practices to lower our rates further. Reviewing evidence -based strategies in the literature, incorporating a multidisciplinary team approach and doing a root cause analysis of current practices combined to expand strategies and lower rates. We experienced decreased rates after implementing the decision tree and new lab-specimen criteria. We also saw a signifcant decrease following the patient bathing practice change. Kimberly Candray, CIC, BS, MT(ASCP), is infection prevention manager at a 300-plus bed hospital in the southwest U.S. References: Mermel LA. Reducing Clostridium diffcile Incidence, Colectomies, and Mortality in the Hospital Setting: A Successful Multidisciplinary Approach. Joint Commission Journal on Quality and Patient Safety. July 2013. Rupp ME, et al. Effect of hospital-wide chlorhexidine patient bathing on healthcare-associated infections. Infection Control and Hospital Epidemiology 2012 Nov; 33(11). APIC Guide to Preventing Clostridium diffcile Infections, 2013. In Practice By Kimberly Candray, CIC, BS, MT(ASCP)

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