Cutting into C. diff rates
Consider the lipstick test in your hospital
Clostridium difficile (C. diff) should sound a lot scarier for what it is: the second most common nosocomial infection in hospitals, with an average cost of $5,000 for each patient episode and an extra week in the hospital.
At WellStar Windy Hill Hospital in Marietta, GA, a program to reduce incidence of the bug led to good results in six months — a 15% reduction — and amazing ones — a decline of more than 44% — by the end of two years.
Windy Hill is a 50-bed long-term acute care center where patients had been bringing C. diff in when admitted and transferring it patient to patient. "The patients are here about 25 days on average and usually on a lot of antibiotics," says Betsy Brakavich, MSN, RN, the vice president and chief nursing officer at the facility. "They are immuno-compromised and old — the poster children for C. diff."
Between 2010 and 2011, there were 50 cases, says Renee Miller, RN, MSN, CPHRM, CIC, infection prevention officer. "It was a large bioburden, and we figured most of the transmission was hand to hand, patient to patient."
They worked with environmental services to find out where the problem areas were in patient rooms by putting 21 lipstick dots in high-touch areas. Staff members were then instructed to clean the room as if it was a terminal clean. Then they looked to see what was left. There were some consistent areas that were missed — like under the bed rails.
Every environmental services employee participated in the test. On average, they found 18 of 21 dots, says Brakavich.
The cleaning crew changed from string to microfiber mops, and started using bleach for cleaning, which at the time wasn't recommended but now is, Brakavich says. Bleach wipes are used on all equipment in the rooms.
Windy Hill also started a new isolation process. Now, if staff or family members are going into a room for a casual connection that does not include touching or doing a procedure, visitors are asked to put on gloves. For the higher-risk times, gown and gloves are required. "It results in better compliance, because people will walk in with nothing at all," says Brakavich. The signage for the new rules wasn't initially noticed, so Milller says they changed it recently to a shocking pink color that's hard to miss.
While a lot of emphasis has been put on having alcohol sanitizing stations in hospital rooms, Brakavich and her team went back to a soap and water mandate for team and family members, which is better at physically scrubbing C. diff from hands and washing it down the sink.
Patients were getting their own blood pressure cuffs, but oral thermometers were kept on the blood pressure machine that went from room to room, so Brakavich wondered if that was potentially another mode of transmission. "We now give everyone a digital thermometer of their own for the length of their stay," she says.
As many items as possible were changed from reusable to disposable, such as basins and slings for Hoyer lifts. Brakavich says that any additional costs are more than made up for by the reduction in infection and its associated costs.
Sister hospitals and community liaisons were educated to look for signs and symptoms of the infection, and education on the new procedures was spread through in-services and daily huddles. Everyone from nurses and patient techs to dietary staff and environmental services received the same education and messages. The project was written about in newsletters and was the subject of puzzles and prizes. "We wanted to keep it front of mind for everyone," Brakavich says.
The changes led to a decline in the number of cases to 29 in a fairly stable population by 2012. In the last four months, there have been just two cases. The goal is zero, Brakavich says.
Miller says they keep track of infections on a big board that includes rates for other hospital-acquired conditions such as falls and other infections. If there is an infection with C. diff, the chart notes the room number, along with the number of days since the last infection, and how many cases in the month before and the year to date.
That doesn't happen very often. Instead, there are a lot of celebrations for "100 days since" some infection or another. The latest was related to central line-associated bloodstream infections, and it's been almost a year since the last case of ventilator-associated pneumonia.
The lipstick comes out periodically, still, and occasionally, someone misses something — a light switch, the bedside table edge, or the TV remote.
"You can't fix this completely because patients will come in with this, and when they do, it's a time bomb," Brakavich says. "Transmission can happen before you know it, and then the patient down the hall has it. You have to be relentless."
For more information on this topic, contact Betsy Brakavich DNP, RN, MPA, NEA- BC, Vice President and Chief Nursing Officer, or Renee Miller, RN, MSH, CPHRM, CIC, Infection Prevent and Employee Health, WellStar Windy Hill Hospital, Marietta, GA. Telephone: (770) 644-1079.