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A community hospital within an academic health care system was struggling with high hospital-onset C. diff infection (HO-CDI) rates. An interdisciplinary team put together evidence-based interventions to successfully reduce HO-CDI rates (Walter 2022). Interventions included: diagnostic stewardship, enhanced environmental cleaning, antimicrobial stewardship and education and accountability. After one year, they achieved a 63% reduction in HO-CDI and have sustained a 77% reduction. The infection rate remained below national benchmark for HO-CDI for over 4 years at a rate of 2.80 per 10,000 patient days.
Interventions recommended in CDC’s “CDI Prevention Strategies” (CDC 2021) were used. A key to any quality improvement program is having clinical champions. Their interdisciplinary team had both unit nurse champions and physician champions. In addition to a strong nursing team leader, they had an infection preventionist, a clinical microbiologist, an epidemiologist, an antimicrobial stewardship pharmacist, and an environmental services representative on the interdisciplinary team.
One important element was development of a new clinical testing protocol. This allowed nurses to test any unformed stool for C. diff without the need for a provider order. The patient with a loose stool would be placed on contact enteric isolation until a negative test result was received.
Another important element was reinforcement that staff members conduct hand hygiene with soap and water rather than hand sanitizer. Programs to improve hand hygiene have often focused on increased use of alcohol-based hand sanitizers. But those don’t kill C. diff spores. Use of soap and water is the best way to eliminate C. diff spores.
Another key was enhancement of environmental cleaning. Environmental services workers changed to a more effective sporicidal disinfectant and started using that in all patient rooms regardless of isolation status. In addition, in patient rooms that were placed under contact enteric isolation for a C. diff infection, cleaning was intensified, including a terminal cleaning with disinfectant and UV light disinfection, and cleaning equipment with bleach wipes.
Their antimicrobial stewardship program focused on reducing the use of fluoroquinolones. Clinical staff could now only order them fluoroquinolones as part of an order set and clinical decision support was built into the electronic medical record to prevent standalone orders for fluoroquinolones.
The addition of an accountability processes further improved compliance with standards of practice. Staff on the team and units received emailed notices about compliance issues and held meetings to discuss how to improve compliance.
Kudos to the team at Emory Saint Joseph's Hospital in Atlanta, Georgia for this successful project!
Some of our prior columns on C. diff infections:
· August 2021 “Updated Guidelines on C. diff”
· October 2021 “HAI’s Increase During COVID-19 Pandemic”
· March 2022 “Predicting C. diff Infection in Just 6 Hours?”
Walter C, Soni T, Gavin MA, et al. An interprofessional approach to reducing hospital-onset Clostridioides difficile infections. American Journal of Infection Control 2022; Published:May 11, 2022
CDC (Centers for Disease Control and Prevention). CDI Prevention Strategies
Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities. CDC
Page last reviewed: December 17, 2021
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