Clostridium Difficile Taking a personal approach

to reduce Nosocomial Infections

Acute Care of the Elders

Surrey Memorial Hospital

Fraserhealth Authority

Disclosure

We have no relevant financial or non financial relationships to disclose

Nosocomial C-difficile was a way of life

The SMH Acute Care for the Elderly (ACE) unit was one of the top 2 units in Fraserhealth (FHA) plagued with nosocomial C.difficile (CDI)

The CDI rate for this unit was very high at 35.1 and 28.6 per 10,000 patient-days, respectively, in comparison to the FHA target of 6.0.

These rates were among the highest across all acute care units in FHA.

Patient population at highest risk

Our patient population at highest vulnerability of any population group:

Complex, frail aging population

Multiple co-morbidities

Multiple antibiotics

Advanced age

Year ending April 1, 2012 we realized 48 nosocomial cases

We began to take it personally

The following year we reduced that to 38

How did we do this?

Discussed the fact that we as a unit had a challenge with C.difficile

Acknowledged to site and regional leaders that C.difficile was a common complication of being admitted to our unit.

Talked about C.difficile with our patients and their families

How did we do this?

Created a multi-disciplinary team;

Management - Older Adult Program Manager Unit leadership - Patient Care Coordinator, Clinical Nurse Educator Front line champions - RNs, Care Aides Unit clerks, Allied health – PT, OT Infection Prevention and Control Practitioners, Housekeeping as well as BISS.

Initial Steps taken…

We audited infection prevention and control practices specific to our unit.

Identified gaps and deviations from recommended best practices.

The audit was conducted using a standard tool developed by

the FH Infection Prevention and Control (IPC) Program.

Gap Analysis identified Key areas to target

Hand washing, hand washing, hand washing

Education needs; staff, physicians, patients, visitors,

Environmental monitoring

Proper accommodation of patients, private is best

Dedicated toileting facilities;

Appropriate collection of stool samples through the use of the Bristol Stool Chart (regardless of admitting diagnosis!)

Staff education around clinical knowledge of CDI and best infection prevention and control practices…physicians too!

Hand hygiene was not a given…

Weekly audits of staff hand hygiene compliance; humour

Established a process for patient hand hygiene (before/after meals, after toileting); involving a neutral wipe using friction and alcohol-based hand rub (ABHR);

Unit Clinical Leadership

Increased hand hygiene audits, at first weekly then biweekly

Daily use of decluttering tool

Daily re-enforcement of Bristol stool chart Regardless of diagnosis, all stool was assessed according to Bristol Stool Chart

ALL patients were considered at risk for CDI

Daily re-enforcement of infection control practice

Housekeeping

Complete cleaning of the unit with sporicidal disinfectant

Strengthening reprocessing practices such as dedicating equipment when possible and cleaning & disinfection of shared equipment;

Ensure proper cleaning techniques

Additional training as required Especially important for replacement housekeepers

Action by housekeeping (at leadership level)

Housekeeping Additional cleaning hours

Change to bleach product

Discard toilet brush and floor mop between every room

Additional audits

Infection Control

Monitor and track cases

Look for patterns

Provided daily support to clinical leaders

Action by Infection Control (at leadership level)

Infection Control leadership supported the unit to upper level leadership

Close hallway beds

Increased environment audits

Action by frontline nursing

Daily use of Bristol Stool chart on ALL patients regardless of admitting diagnosis

Collection of specimen after 3 X #7 (stool must meet criteria for C Diff, not physician order or the result of laxative use). prevented taking colonized specimens.

Staff became proactive; not afraid to confront fellow staff members and visitors about following strict isolation practices. Classic conversation now is, “are those clean or dirty?”

More targeted action

Individual use equipment BP Cuff Transfer belt Toiletries PT Equipment

Patient Hand Hygiene Moist wipes before every meal

Personal hand sanitizer

Unit practices began to change

Declutter family members asked to take home

personal belongings Eliminate any storage of supplies in

patient area

Remove linen carts from the halls Reduce clutter at bedside Eliminate clutter on window ledges

Action by Unit Clerk Identified patients with confirmed or suspected CDiff by using

a coloured dot on their patient board.

Communicated to porters, lab, etc that the patient was suspected or confirmed CDiff.

Once the third #7 stool specimen sent... Patient instantly put on contact precaution plus until proven negative.

Made sure clear signage on the patient’s doors re: contact precautions

Cleaned phone, keyboard and mouse with Virox

Frequent terminal cleans for when patient off floor (test, shower etc)… all aimed at reducing bio-burden.

Action by Manager

Ensured staff felt supported and not "on their own"...

Available 24/7 to support In Charge’s decisions

“conversations" with site leaders during times of congestion

Staff observations/challenges with lab, porters and housekeeping… would be escalate to educate the site.

Support unsung heroes

Be open with those staff seeking employment that we have a C Diff problem

A shift in culture

Any staff, physician or visitor observed in Personal Protection Equipment was challenged “are you clean or dirty”

Reduce that bio-burden! All practices focused on reducing,

‘bio-burden”

“When in doubt isolate”

“When in doubt, throw it out”

Results were dramatic!

Reduced C Diff rates (Only 4 cases from April to September last year)

Increased staff morale

Success is a huge motivator