C. difficile (C. diff) is the most common cause of healthcare–associated diarrhea in U.S. hospitals. Reducing healthcare-acquired Clostridium difficile infections (CDIs) is a complex and evolving battle. But it’s a battle that can be won. At Mercy Health — St. Anne Hospital, a 100-bed community hospital in Toledo, Ohio, my team and I used a multi-component strategy to reduce CDI rates and from July 2016 to July 2017 successfully eliminated all healthcare-associated CDI cases.
Prior to 2015, St. Anne Hospital had 40% more infections than predicted from baseline. Aiming to improve, my team and I worked with administration at both the hospital and system level to reduce the hospital’s rate of CDI. We began by initiating a “days since last” approach on the hospital’s daily safety call. Each unit shared their daily CDI-related information including number of patients on the unit with known or suspected CDI, number awaiting specimen collection or results, and what day of hospitalization CDI was confirmed. While this call was effective in bringing CDI to the forefront of attention, more needed to be done.
In 2015, we started tracking CDI cases by their location in the hospital. This showed nearly all cases of CDI patients spent time in the ICU, so my team and I ensured each ICU room underwent additional steps in terminal cleaning using bleach and UV light. In addition, we implemented a policy that required the cleaning of suspected and confirmed CDI patient rooms with bleach, exchanging privacy curtains, and cleaning with UV light at every transfer or discharge, regardless of location. This policy also emphasized routine bleach cleaning of areas within the ICU that were prone to frequent touch such as the nurses’ station, hallway handrails, and door handles.
We educated healthcare personnel on appropriate testing, the accuracy of PCR testing, and proper specimen collection. We then implemented policies to assess for diarrhea and C. difficile risk factors at the time of admission. Patients were asked about recent antibiotic use, healthcare visits, and diarrhea. Finding patients with diarrhea and at least one other risk factor would prompt the nurse to immediately isolate the patient and obtain an order for a stool specimen. Isolation was discontinued only if C. difficile was not detected by PCR in the ordered stool specimen, or if the patient did not have watery stool in a 24-hour period. The pediatric Bristol scale helped standardize the description of stool consistency by both staff and patients.
Simultaneously, the hospital’s Infection Prevention and Pharmacy departments implemented an antimicrobial stewardship program (ASP). This program engaged both clinicians and hospital leadership such as the CEO, CMO, infectious disease physicians, and managers from departments of quality, lab, nursing, and education. The ASP staff reviewed charts for duplication of antimicrobials and de-escalation when appropriate. The use of order sets with appropriate antibiotics for diagnoses such as sepsis, community-acquired pneumonia, and UTI was encouraged for emergency department use as well as for admission orders.
The final component of the intervention involved changing contact precaution signs placed outside of CDI rooms and adding a weekly glove and gown compliance report to the safety calls. The new contact precaution signs emphasized strict adherence to the use of gowns and gloves, hand hygiene, and bleach disinfection of shared patient care items before use by another patient.