Driving infection rates to zero is a worthy aspirational goal but it is seldom accomplished in reality, particularly with Clostridium difficile.
This spore-former resists eradication on healthcare worker hands and the patient environment, explaining in part why it is proving one of the most difficult infections to reduce in national surveillance data. But an infection preventionist in Ohio drove C. diff to zero for a stunning 341 days with a multifaceted program that had buy-in from healthcare colleagues and hospital administration.
“When it comes to C. diff, people believe that just being below a benchmark is enough,” says Lisa Beauch, BSN, RN, CAPA, CPAN, CIC, regional infection prevention manager at Toledo Mercy Health-St. Anne Hospital. “Everybody thinks that zero is impossible. While it is a lot of hard work, it is possible.”
More from Beauch shortly, but consider the difficulty of this task in light of national data recently released by the Centers for Disease Control and Prevention (CDC) in San Diego at the IDWeek 2017 meeting. As a follow-up to a 2011 study, the CDC surveyed 143 of the same hospitals in 2015 for prevalence of healthcare-associated infections (HAIs). Data from nearly 9,000 patients showed declines in surgical site infections, UTIs, and central line infections, but C. diff infections did not budge.
“HAI prevalence was significantly lower in 2015 compared to 2011 … suggesting national efforts to prevent SSIs, reduce catheter use, and improve UTI diagnosis are succeeding,” the CDC concluded.1 “By contrast, there was no change in the prevalence of the most common HAIs in 2015, pneumonia and C. diff, indicating a need for increased prevention efforts in hospitals.”
As IPs are well aware, this is no inconsequential infection. C. diff is a common cause of diarrhea in hospitalized patients, but can escalate to life-threatening complications in the gastrointestinal tract in infections that are directly attributable to the death of some 15,000 patients annually, the CDC estimates.
Key interventions at Beauch’s 100-bed hospital include monitoring compliance with hand hygiene and barrier precautions, an enhanced cleaning regimen, and antibiotic stewardship. After patient transfer or discharge, rooms of suspected or confirmed C. diff patients are cleaned with bleach and disinfected with UV light, and privacy curtains are changed. The policy also emphasized routine bleach cleaning of high-touch areas, including the nurses’ station and door handles. To put the issue brightly on the radar, Beauch began posting “days since last” C. diff infection. We asked her to tell us more about the successful program in the following interview.
‘We were so close’
HIC: You note that prior to 2015, your hospital had 40% more C. diff infections than it should for its demographics and patient population. Can you comment further on that?
Beauch: Based on our size and the community burden of C. diff, the CDC’s National Healthcare Safety Network gives a standard infection ratio. They estimate this based on our risk factors and how many potential infections we should have. So, say we should have 10 C. diff infections, but we had 14. That would be 40% more than they felt we should have. Of course, the goal is always zero. One is too much, that goes without saying, and we keep pounding that home. We could no longer tolerate [the attitude of] “as long as we are below what is expected, we’re fine.”
HIC: Given the tenacity of C. diff, it is remarkable that your hospital almost went a full year without a healthcare-associated infection.
Beauch: We went 341 days — from July 27, 2016 to July 4, 2017. It was pretty devastating. We had our daily safety call, and when the manager announced it you could just hear everyone give out a collective sigh. We were so close. I had a party planned — we were planning on a big celebration. We still celebrated — don’t get me wrong — but to have made it to 365 days would have been just amazing. We celebrated the success that we did have and started over again. We had those cases in July and now we’re back to zero.
HIC: How do you define a nosocomial case of C. diff?
Beauch: The lab ID event is very cut and dry. If they have a positive specimen day four or later in their stay [it’s hospital-associated]. The expectation is that if they would have come in with it, we would have tested for it in the first couple of days.
Sometimes things do slip through the cracks and that is part of the education that we do. We are asking questions right at admission. We are testing them and appropriately getting them classified as community-acquired.
There is a consistency of stool that should be tested and should not be tested. We shouldn’t be testing formed stool. Sometimes tests are ordered on stool that don’t meet criteria. We are trying to change that mindset. By definition, C. diff is three or more watery stools in a 24-hour period. So if a patient is having formed stool, they do not have C. diff. They could be a carrier. There are people who carry C. diff and are asymptomatic, but we are actually testing for active C. diff. We isolate active cases. The way that C. diff is transmitted is obviously the stool. Normally, a patient who is continent and washes their hands is not an issue.
HIC: You had multiple interventions so it is probably difficult to single out any one thing. What is your basic role in the program?
Beauch: It does no good for me to stomp my feet, yell at the walls, and say, “We have a C. diff problem.” You’ve got to get out there. I go out and talk to the nurses and find out what’s going on, where are we at? Just getting everybody speaking the same language is huge. We do education with the physicians because we do PCR testing that is very accurate. So a negative is almost certainly a negative.
HIC: In terms of antibiotic stewardship, did you target certain drugs that are known to trigger C. diff by wiping out the commensal bacteria in the patient gut?
Beauch: There are antibiotics that are at a higher risk of causing C. diff — if you have been exposed — than others. But more importantly we would find that, for example, in a chronic obstructive pulmonary disease (COPD) patient. Typically, no antibiotic or a single antibiotic is appropriate for COPD. We found that physicians were hitting them with two or three antibiotics like they have pneumonia, when in fact they have COPD. We don’t want them putting patients on a broad-spectrum, throw-everything-but-the-kitchen-sink antibiotic if they don’t have pneumonia. That exposes them to a lot of antibiotics that they probably don’t need. It just happened that the clinical pharmacist and I were both trying to get an antimicrobial stewardship program up and running at a more robust level. C. diff ended up being a nice tie-in because we already had administrative support for stewardship. It’s way more than a three-legged stool — environmental cleaning, hand hygiene, antimicrobial stewardship. We have found it is also appropriate [to have] testing, education, and administrative support. It ends up being a lot.
HIC: How does your infection control compliance reporting work?
Beauch: Every day I round, and I have some “secret shoppers” that round as well. As I am walking down the halls by the isolation rooms I will look in, if the door is open, and see if everybody is wearing appropriate PPE. I then write down the person’s name and the department. At the end of the day I email that list to all of the managers of the staff I saw. So if it was a nurse on med-surge, I send it to the med-surge manager. If it is a dietician, I send it to the dietary office. This is everything — good or bad.
HIC: That’s interesting. You report people who are compliant?
Beauch: Recognition is just as important as having an intervention if they are not complying. When I see people that are not compliant, I wait until they come out and then have a conversation right there — immediate feedback. We discuss what was going on. Today, I had a conversation with a couple of nurses. They were upset because they were in an isolation room without a gown, but the bed alarm was going off — the patient was half out of the bed. I told them, of course, our patients always come first, but they are so in tune now to these conversations. The staff know that both the good and the bad are going to be reported to their managers. Mercy Health as a whole has a zero-tolerance policy and the expectation for hand hygiene 100% of the time, whether the patient is in isolation or not.
HIC: Were you able to determine what caused the infections that ended your zero streak?
Beauch: We ended up having three. One we really could not tell, it may have actually been a case of [nosocomial] C. diff. The other two appeared to be inappropriate testing. They sent non-diarrhea stool and it got tested. But it ends up being hospital-acquired because the patients were in day four or after. So, we go back and educate again. It’s a bell you just have to keep ringing. We’re trying and it truly takes a village. You could not do this alone, nor should you. Infection prevention is supposed to be the facilitator. You have to get the buy-in from every level. We talk about this every day, and the isolation compliance and hand hygiene is reported once a week. That gets sent out and it is posted, so everybody gets called on the carpet. Where was the breakdown and where can we go from here? What do we have to do to keep this from happening again? This represents the great work of everybody in this building and they have done a phenomenal job of taking this and running with it.
- Magill SS. Wilson LE, Thompson DL, et al. Reduction in the prevalence of healthcare-associated infections in U.S. acute care hospitals, 2015 versus 2011. Session: Oral Abstract. Session: National Trends in HAIs. Abstract 1768. IDWeek 2017. Oct. 4-8, 2017. San Diego.