clinical guided project presentation
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Infection Control: C. diffTRANSCRIPT
Clinical Guided Project - PresentationNUR 440: Dr. Deborah Garrison and Nancy BucherBy: Krystal DeSantis, Lucy George & Melinda Gillies
Due: November 28, 20121
Infection Control: Clostridium difficile
Clinical Issue
2
Clostridium Difficile
40% affected in hospital setting
Surpasses MRSA infections
Infection Control
(Grossman & Mager, 2010, p. 155) – 40% affected
(Page, 2011, p.8) - MRSA
Evolution of Clostridium difficile
3
1930’s: Identification
1970’s: Health issues
1978: “Infectious cause of antibiotic-associated diarrhea”
(Keske & Letizia, 2010, p. 329)
Strains of Clostridium difficile
4
Toxin A
Toxin B
NAPI
(Grossman & Mager, 2010, p. 155) – Toxin A and Toxin B
(Evans, 2012, p. 39) - NAPI
Mode of Transmission
5
Fecal-oral route
Issue at hand
Objects
(Pelleschi, 2008, p. 28) - transmission
(Keske & Letizia, 2010, p. 330) - objects
Individual Risk Factors
6
Antibiotic Use
Advanced Age
Surgery
Chemotherapy
Severe illnesses
Decreased stomach acidity(Pelleschi, 2008, p. 29)
Signs and Symptoms
7
Ranging from mild to severe
Systemic Complications
(Pelleschi, 2008, p. 29-30)
Development of Clostridium difficile
8 (Pelleschi, 2008, p. 28)
Example of Clostridium difficile
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Cancer patient with Clostridium difficile infection
Chemotherapy
Risk factors
Patient History
Nursing Role (Winkeljohn, 2011, p. 215-216)
Quantitative Data: Clostridium difficile
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Age group affected
Amount of individuals affected
Costs for treatment
Mortality rate
(CDC, 2012, p. 157-158)
HAI PreventionPA Dept. of Health requires all hospitals to
report HAIs within 24 hours of occurrence
PADOH supports a prevention collaborative between hospitals in southeastern PA to reduce the occurrence of CDIs
11
Healthcare-Associated Infections (HAI) Report: Q+A. (2011).Retrieved from http://www.portal.state.pa.us/portal/server.pt/community/healthcare_associated_infections/14234
Infection Control & Prevention
An estimated 94% of CDIs are potentially avoidable through responsible antibiotic use and the prevention of horizontal transmission (Cohen et al., 2010)
Hospitals instituting infection control and prevention programs were successful in reducing CDI rates by 20% over a period of 21 months. (CDC, 2012)
12
Cohen S et al. Infect Control Hosp Epidemiology 2010; 31(5), 431-455.CDC (2012). Vital signs: Preventing Clostridium difficile infections. Morbidity & Mortality Weekly Report – MMWR, 61(9), pp. 157-162.
Antibiotic Stewardship
Reduce overuse and inappropriate selection of antibiotics
Shorter duration of treatment
13Cohen S et al. Infect Control Hosp Epidemiology, 2010; 31(5), 431-455.
Components of an Infection Control & Prevention Plan
An early detection systemInterruption of person-to-person spreadElimination of environmental
contamination Education, and Monitoring
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Early Detection
Increasing the number of diarrheal stool tested for C. difficile
Recognizing the limits of toxin A/B immunoassay
Laboratory-based alert system for immediate notification of positive test results
Nurse-driven protocol for stool testing
15
Cohen S et al. Infect Control Hosp Epidemiology, 2010; 31(5), 431-455. Christine Young, personal communication, October 16, 2012
Interruption of Horizontal Transmission
Place all tested patients on preemptive contact precautions/isolation for pending confirmation of CDI
Extend use of contact precautions/isolation beyond duration of diarrhea (e.g., until discharge and if readmitted within 6 weeks)
16
Sethi AK et al. Infect Control Hosp Epidemiology; 31(1), 21-27. C. Young, personal communication, October 16, 2012
Justification for Extending Contact Isolation
17 Bobulsky G et al. Clin Infect Dis 2008;46:447-50.
Interruption of Horizontal Transmission
Implement soap and water for hand hygiene
Hand hygiene for patients Personal protective
equipment Use of dedicated non-
critical medical equipment
Visitor requirement/restrictions
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Elimination of Environmental Contamination
C. difficile spores can remain on surfaces for long periods of time and are resistant to commonly used disinfectants.
Transmission of C. difficile from patient-to-
patient is directly proportional to the amount of environmental contamination.
19 Weber D et al. Am J Infect Control 2010; 38(5 Suppl 1):S25-33.
Environmental Cleaning
Reduces the load of C. difficile spores within the environment preventing the transmission of the disease to uninfected patients.
Recommendations include routine daily isolation cleaning using a low-level disinfectant.
Terminal cleaning with a 10% chlorine-based product: results in a 48% reduction in the prevalence density of C. difficile.
20
CDC (2012). Vital signs: Preventing Clostridium difficile infections. Morbidity & Mortality Weekly Report – MMWR, 61(9), pp. 157-162. Hacek, D et al. Am J Infect Control 2010; 38(5), 350-3.
Supplemental Measures for High –Risk Units
High loads of C. difficile spores or outbreaks of CDI will necessitate daily cleaning with Clorox ultra-germicidal bleach wipes containing 6.15 percent sodium hypochlorite.
Orenstein (2011) showed daily use of these wipes on a high-risk unit “effectively reduced the acquisition rates of CDI by one-third and time between cases from 8 to 80 days.”
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Orenstein R et al. Infect Control Hosp Epidemiology 2011;32(11), 1137-9.
Education of Hospital Personnel
Annual education regarding CDI prevention with special attention to appropriate hand hygiene and contact isolation precautions
Re-education of staff if the hospital experiences an outbreak
Allen and Nones-Cronin (2012) report an increase in staff members’ compliance with infection control measures after educational intervention
22
Allen S et al. Dim Crit Care Nurs 2012, 31(5), 290-294. Retrieved from CINAHL database. Carboneau C et al. J Healthc Qual 2010 ; 34(4) 61-70.
Impact of Education Intervention
Important in overcoming barriers to effective implementation
Inconsistent cleaning of high-touch surfaces (i.e. bedrails, telephones, call buttons, door knobs, toilet seats, and bedside tables)
Educational intervention for housekeeping staff resulted in a 70% reduction in positive cultures for C. difficile
23 Eckstein B et al. BMC Infect Dis 2007; 7, 61.
Education of Patients & Visitors
Basic facts
Infection Control Measures
Special discharge teaching – patients may be at an increased risk for developing CDIs up to 3 months after hospital discharge
24 Murphy C et al. Infect Control Hosp Epidemiology 2010; 33(1), 20-28.
Monitoring
Determines the success of the infection control and prevention program
Ensures the continual use of best practices by hospital staff and helps to determine if interventions are positively impacting patient outcomes
Effectiveness of environmental cleaning by housekeeping
25
Guh, A., & Carling, P. (2010). Options for evaluating environmental cleaning. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf
Monitoring (continued)
Track monthly compliance with infection control measures including hand hygiene and PPE use
Track number of CDIs per 1,000 patient days
Effectiveness of environmental cleaning by housekeeping staff will also be assessed.
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Cost Savings
Centers for Medicare and Medicaid Services (CMS) will reduce or eliminate payment for hospital-acquired CDI.
Hospitals responsible for cost of treatment estimated at $35.7 billion to $45 billion for in-patient services
Potential annual savings due to infection control measures range from $5.7 billion to $31.5 billion
27
Scott, R. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Quantum Leadership Theory
Shared decision makingCoachingMentoring
Employee empowerment
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Successful and Effective Leader
Constructs effective teams
Shared vision
Believes every employee is unique and important
(Ercetin and kamaci, 2008)
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Communication
Necessary for successful decision making and implementing change
Active listening essential
Leader must be able to acknowledge and respond to staff emotions
(Porter-O’Grady & Malloch, 2011)
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Communication (continued)
Important to have effective plan of early communication to implement a change
Everyone affected by proposed plan of change should be involved
Imperative to provide as much information as possible
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Implementation of an Infection Control Plan
Establish infection control committeeMultidisciplinary teamOne member trained in infection control, responsible
for education, surveillance and trackingPerform risk assessment to guide plan implementation Investigate and analyze clusters of Clostridium difficile
infectionData collected and analyzed for infection and manner
of spread Information kept in computer and manualHope to decrease to decrease CDI within six months
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Proposed CDI Plan
Hold in-service for all medical staffEducate staff regarding what C.diff is and the
mode of infection transmissionExplain importance of rapid identification to place
patient in isolationImportance of contact precautions explained
Educate staff on personal protective equipment (PPE)
PPE includes use of gloves and gownsEducate staff on how to put on and remove PPE
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Implementation of Contact Precautions Protocols
Staff expected to demonstrate proper way to put on and remove PPE
Point person assigned to units to assure PPE readily available
Point person to ensure staff compliance Point person will keep surveillance forms and
send to infection control committee
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Hand Hygiene Education
Critical element of plan
Essential to eliminating CDI outbreaks
Only acceptable method is soap and water
Quizzes given to staff to ensure understanding
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Implementation of Hand Hygiene Protocols
Hands to be washed for at least 15 seconds before and after entering a patient’s room
Point person assigned to perform hand washing checksMonitor use of soap and waterUse skill validation check listUse check list as a tool to counsel staff as needed
Staff encouraged to ask each other about hand washing
(Pyrek & Orenstein, 2010)
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Environmental Cleaning
Transmission of contaminated patient surfaces and medical equipment is significant if not cleaned properly
Important to educate housekeeping on cleaning high touch areas to eliminate spread of infection
Daily cleaning of high touch areas vital Educate staff to use 10% chlorine bleach solution or
bleach wipes. Educate importance of cleaning bathrooms twice a day Educate importance of dedicated cleaning equipment to
be kept in patient’s bathroom
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Implementation of Environmental Cleaning
Hygiene
Environmental manager in charge of monitoring appropriate chemicals being used
Environmental manager will utilize Digiglo light to evaluate proper disinfecting
Digiglo will be used to decide if further education is needed regarding cleaning is required
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ConclusionNot one strategy alone can eradicate or lower
CDICombination of antibiotic control, good hygiene
and environmental cleaningHold staff accountable with help of
management and infection control committeeRegular education of staff is an important
driving force behind lowering CDI ratesHave staff demonstrate competencyMost important factor behind implementing
change is patient safety
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References Allen, S., & Nones-Cronin, S. (2012). Improving staff compliance with
isolation precautions through use of an educational intervention and behavioral contract. Dimensions of Critical Care Nursing, 31(5), 290-294. Retrieved from CINAHL database.
Bobulsky, G., Al Nassir, W., & Riggs, M. (2008). Clostridium difficile skin contamination in patients with C. difficile-associated disease. Clinical Infectious Diseases, 46, 447–450.
Carboneau, C., Benge, E., Mary T. Jaco, M., & Robinson, M. (2010). A lean six sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%. Journal for Healthcare Quality, 34(4) 61-70. Retrieved from CINAHL database.
Cohen, S., Gerding, D., Johnson, S., Kelly, C., Loo, V., McDonald, L., Pepin, J., & Wilcox, M.(2010). Clinical practice guidelines for C. difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. Infection Control and Hospital Epidemiology, 31(5), 431-455. Retrieved from CINAHL database.
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References (continued) Eckstein B., Adams, D., Eckstein, E., Rao, A., Sethi, A., Yadavalli, G., & Donskey,
C. (2007). Reduction of Clostridium Difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BioMed Central Infectious Diseases, 7, 61. Retrieved from CINAHL database.
Ercetin, S., & Kamaci, M., (2008). Quantum Leadership Paradigm. World Applied Sciences Journal, 3(6), 865-868. Retrieved from http://www.idosi.org/wasj/wasj3(6)/1.pdf
Evans, G. (2012). Time to put the gloves on: C. diff patients death hit a historic high. Hospital Infection Control & Prevention, 39(4), pp. 37-42. Retrieved from CINAHL EBSCO Host database.
Grossman, S. & Mager, D. (2010). Clostridium difficile: Implications for nursing. MEDSURG Nursing, 19(3), pp. 155-158. Retrieved from CINAHL EBSCO Host database.
Guh, A., & Carling, P. (2010). Options for evaluating environmental cleaning. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf
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References (continued) Hacek, D., Ogle, A., Fisher, A., Robicsek, A., Peterson, L. (2010).
Significant impact of terminal room cleaning with bleach on reducing nosocomial Clostridium difficile. American Journal of Infection Control, 38(5), 350-3.
Healthcare-Associated Infections (HAI) Report: Q+A. (2011). Retrieved from http://www.portal.state.pa.us/portal/server.pt/community/healthcare_associated_infections/14234
Keske L. A. & Letizia, M. (2010). Clostridium difficile infection: Essential information for nurses. MEDSURG Nursing, 19(6), pp. 329-333. Retrieved from CINAHL EBSCO Host database.
Murphy, C., Avery, T., Dubberke, E., & Huang, S. (2012). Frequent hospital readmissions for Clostridium difficile infection and the impact on estimates of hospital-associated C. difficile burden. Infection Control and Hospital Epidemiology, 33(1), 20-28. Retrieved from CINAHL database.
Orenstein, R., Aronhalt, K., & McManus, J. (2011). A targeted strategy to wipe out Clostridium difficile. Infection Control and Hospital Epidemiology, 32(11), 1137-9. Retrieved from CINAHL database.
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References (continued) Page, S. (2011). C. difficile surpasses MRSA as leading cause of
nosocomial infections in community hospitals. New Hampshire Nursing News, 35(1), p. 8. Retrieved from CINAHL EBSCO Host database.
Pelleschi, M. E. (2008). Clostridium difficile – Associated Disease: Diagnosis, prevention, treatment and nursing care. Critical Care Nurse, 28(1), pp. 27-36. Retrieved from CINAHL EBSCO Host database.
Porter-O’Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing innovation,
transforming healthcare. Sudbury, MA: Jones & Bartlett Learning. Pyrek, K., & Orenstein, R., (2010). Cleaning Intervention Cuts C. difficile
Acquisition Rates by One-Third. Retrieved fromhttp://www.infectioncontroltoday.com/s.aspx?exp=1&u=http%3A//www.infectioncontroltoday.com/
Scott, R. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
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References (continued) Sethi, A., Al-Nassir, W., Nerandzic, M., Bobulsky, G., & Donskey, C.
(2010). Persistence of skin contamination and environmental shedding of C. difficile during and after treatment of C. difficile infection. Infection Control and Hospital Epidemiology, 31(1), 21-27.
Weber, D., Rutala, W., Miller, M., Huslage, K., & Sickbert-Bennett, E. (2010). Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. American Journal of Infection Control, 38(5 Suppl 1):S25-33. Retrieved from CINAHL database.
Weiss, K., Boisvert, A., Chagnon, M., Duchesne, C., Habash, S., Lepage, Y., Letourneau, J., Raty, J., & Savoie, M. (2009). Multipronged intervention strategy to control an outbreak of Clostridium difficile infection (CDI) and its impact on the rates of CDI from 2002 to 2007. Infection Control & Hospital Epidemiology, 30(2), 156-162.
Winkeljohn, D. (2011). Clostridium difficile infection in patients with cancer. Clinical Journal of Oncology Nursing, 15(2), pp. 215-217. doi:10.1188/11.CJON.215-21
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