A hospital in Medford, OR, reduced its rates of C. difficile infections by three-fourths with a targeted approach intended to identify exactly what strategy is the most effective after previous attempts left hospital leaders wondering which of several interventions had worked.
Asante Rogue Regional Medical Center, the largest of three hospitals in the Asante system, experienced unacceptable rates of C. difficile infections. The trend continued upward, and hospital leaders tried to address the problem in 2013, says Holly Nickerson, RN, BSN, director of accreditation at the largest of three Oregon hospitals in the Asante system. They saw some success, but they implemented many different strategies in a “shotgun approach,” she says, so they didn’t know which affected the infection rate. Thus, the improvement was short-lived.
“We tried a ton of things all at the same, so we had no idea what worked,” Nickerson says. “We changed our cleaner, we were doing hand hygiene campaigns, all sorts of things that we thought would lower the infection rate. The rates fell some but we couldn’t sustain it, and after we changed our cleaner, the infection rate actually increased.”
In late 2014, the vice president of medical affairs declared the hospital’s C. difficile rate a critical issue and sought strategies for reducing the weekly infection rate, which was about four per week at that time. The Asante system formed a “Green Team” to study recent C. difficile cases and develop possible interventions. Green was chosen because the Asante metrics scorecard use that color to indicate good results.
Root Causes Identified
The system-level team was multidisciplinary, bringing together nursing staff and leadership, infection prevention, pharmacy, environmental services, performance improvement, electronic charting, clinical nurse specialists, nursing professional development, and purchasing. The other two hospitals in the Asante system were outperforming Rogue Regional on C. difficile prevention, so the team looked to them for best practices.
The team found that the infections stemmed from three sources: inappropriate testing, healthcare worker transmission, and environmental services issues. The Green Team then developed strategies for addressing each of those sources of infection. For the inappropriate testing, the team determined that the hospital’s multidrug-testing protocol could be at fault. The protocol allowed nurses to order C. difficile testing any time, which was intended as a good proactive step toward detecting infections. “Test early and test often” was the school of thought.
But it seemed that some positive results were classified as hospital-acquired when they were present on admission, Nickerson explains. Poor communication among nurses sometimes led to a C. difficile test being performed after a patient had received laxatives or medications causing diarrhea, and no C. diff test was performed on admission, a positive test during the hospital stay might automatically be deemed hospital-acquired.
“We know that many patients, especially patients that kind of live in the healthcare system, are colonized with C. difficile, so you may have someone who is shedding spores but who does not have active C. difficile,” Nickerson explains. “By giving them laxatives, we might be just capturing some normal flora that lives in their bowel. We had to help staff understand when to test.”
To address that issue, hospital leaders discontinued the policy of testing for C. difficile under the multidrug-resistant organism protocol at any time, instead encouraging physicians to order specimen collections only when the patient fit appropriate criteria. This was a turnaround from previous hospital policy, so it took some effort to reeducate nursing staff, says Bella Lucas, RN, BSN, manager of infection prevention at Asante Rogue Regional Medical Center.
“It was very much ingrained in the staff to use proactive thinking and wonder if a problem could be C. difficile. They were taught to test early and isolate it to prevent the spread of infection,” Lucas says. “The staff were perplexed by the idea that now the testing would require a physician consult and buy-in.”
Audits for Enteric Procedures
Infections originating from healthcare workers were addressed with daily enteric precaution audits that provided real-time feedback to staff regarding their compliance with procedures for entering and leaving enteric precaution rooms. In addition to immediate feedback, the compiled audit results are provided to staff on a regular basis. When a C. difficile infection is traced to healthcare worker transmission, frontline staff are gathered for an immediate huddle to discuss the case and what precautions may have failed.
For the environmental services issues, the Asante Green Team determined that terminal room cleans were not meeting expectations, with only a 55% passing rate. The root cause, the team discovered, was that the environmental services teams followed no protocol for terminal room cleans. Morale and commitment to the job also were lacking, Nickerson says.
“When I had one of our continuous project improvement leaders meet with that group, it was very apparent they had no standardized process for cleaning their rooms. We use the fluorescent gel dot system that is placed in key areas to test how well the room is cleaned, and it consistently showed poor performance,” she says. “The environmental services team knew where the dots were placed and still were failing the room. That was a pretty big red flag for us that they did not have a process and did not know how to clean the room.”
Those problems were addressed through weekly meetings with a performance improvement project leader to establish a standardized process for terminal room cleans and retrain all staff. The leader also worked to improve their morale by emphasizing the importance of their jobs and how attention to deal can have a direct effect on individual patients.
Cleaning Staff Retrained
The chief of quality and safety met with the environmental services team to emphasize the importance of their roles in patient safety. News items in the hospital newsletter praised cleaning teams for their work and promoted them as vital to protecting patients.
“It was a big retraining process, a big commitment from our environmental services leaders in monitoring and coaching their staff,” Nickerson says. “It came to the staff receiving disciplinary action if they did not clean the rooms properly. We also went to great lengths to stress that they don’t just clean rooms: They help people keep from getting infections.”
The effort was successful, raising terminal room cleaning performance from a 55% passing rate to 100%.
Over the course of nine months, the hospital’s C. difficile infection rate fell from four per week to one per week.
“The effort showed us that you can’t really reduce infections if you don’t have a full understanding of why they’re occurring, and what variables could have an influence,” Lucas says.
SOURCES
- Bella Lucas, RN, BSN, Manager of Infection Prevention, Asante Rogue Regional Medical Center, Medford, OR. Telephone: (541) 789-5402. Email: [email protected].
- Holly Nickerson, RN, BSN, Director of Accreditation, Asante Health System, Medford, OR. Telephone: (541) 789-4358. Email: [email protected].
