Cleaning Up C. Diff, Together

This article appears in the March 2012 issue of HealthLeaders magazine.

Of the long list of contagious infections quality leaders deal with, Clostridium difficile is perhaps the most troublesome. And as if the original infection wasn't bad enough, many hospitals are starting to see NAP1 and other hyper-virulent strains. But in the face of this increasingly resistant adversary, some organizations are forming interdisciplinary task forces and successfully decreasing C. diff incidence by changing the way staff cleans and administers antibiotics.

In 2004 at Hunterdon Medical Center in Flemington, NJ, quality leaders started noticing that C. diff patients were presenting differently and had stronger symptoms than previous C. diff patients. They also saw more cases—the number of C. diff infections more than doubled between 2002 and 2006.

"It used to be common if people [with C. diff] stopped antibiotics they'd get better and didn't require treatment, but these folks really needed treatment and we were seeing readmission with reoccurrence and people with much more time spent in the hospital," says Kathy Roye-Horn, RN, CIC, director of infection prevention at Hunterdon, a 145-staffed-bed nonprofit community hospital. "We could see the disease had changed."

It was in fact the NAP1 strain, which emerged around the year 2000 and makes patients that it infects sicker and is more likely to cause illness when it becomes colonized in a patient.

"In the case of NAP1, not only does it produce more toxin plus an additional toxin, it is also highly resistant to fluoroquinolone antibiotics that began to be more widely used in older patients in the late 1990s," according to L. Clifford McDonald, MD, senior advisor for science and integrity for the division of healthcare quality promotion at the CDC. "This provided an important selective advantage to NAP1, promoting its spread across North America and Europe—further emphasizing this is a public health problem as much as a healthcare quality problem, and both viewpoints must be employed to control this."

Developing a task force
When Roye-Horn alerted the CDC to the changes in C. diff patients at Hunterdon, she discovered that it was among the first hospitals in the United States to develop the NAP1 strain. At the time there was very little literature and best practices regarding how to minimize this kind of C. diff, so Roye-Horn met with Marita Nash, Hunterdon's director of environmental services and linen, to develop a plan of attack.

The pair identified what products were working from a chemical cleaning perspective and what was not. They also discussed medical and nonmedical surfaces that may have been previously overlooked by cleaning crews.

Chemically, they landed on a hypochlorite bleach solution. As for surfaces, Roye-Horn and Nash decided cleaning crews should wipe down computer keyboards and mice, medical record chart covers, telephones, and other nonmedical devices—in addition to other medical devices regularly cleaned. Hunterdon also washes cubical curtains and instructs staff to use soap and water rather than hand sanitizer.

A task force was established and developed specific cleaning protocols after observing staff cleaning routines.   As changes were implemented, the task force grew.

"It became bigger because it really required more staff, and a more consistent approach to cleaning and changing products," Roye-Horn says. "It resulted in a lot of changes in how things were being cleaned and who was cleaning, not just environmental services staff, but the clinical staff that needed to clean things that previously hadn't been cleaned."

Nash notes that "Although staff was doing a good job, each person was doing it in their own way. We began a more streamlined approach, and we went to a two-step cleaning process where you clean once and then a second time in isolation rooms." 

The two-step process was helpful in mitigating oversights. For example, if an environmental service employee wiped down one bed rail and then became distracted, he or she may have forgotten to wipe the other rail. By having to clean every surface twice, this oversight becomes less likely. And the physical act of wiping—rather than merely spraying a cleaning product—is especially critical with C. diff.

"It used to be all about the product and we thought if you were using a good product you wouldn't have to be concerned about the healthcare environment," Nash says. "This is an organism where a typical disinfectant doesn't kill it. What we were trying to do with cleaning was not so much kill the bug but remove it."

The Jewish Hospital–Mercy Health in Cincinnati also focused on environmental cleaning when its C. diff incident rate reached a record high in 2009. Though the 209-staffed-bed hospital did not have the NAP1 strain, its C. diff rate was particularly alarming because the organization cares for a high volume of elderly patients, so leaders formed a task force to quickly bring down infections.

In 2009 the hospital's C. diff incidence rate was 25.27 per 10,000 patient days. Quality leaders set an initial target of a 10% reduction, with a goal of 22.74.

The hospital formed a task force made up of nurses, physicians, administrators, and staff from infection prevention, pharmacy, and environmental services.

"The task force focused on the units with highest rates of infection," says Azalea Wedig, infection preventionist. "We did a risk assessment, brainstormed, and assessed and decided to target three areas—the broad spectrum antibiotic use, environmental cleaning, and standardization of clinical care."

The task force started with environmental care and looked at how clean the environment was, the cleaning products  used, how often staff changed and washed cubicle curtains, and how they performed the C. diff isolation process.

The hospital started changing the curtains after all C. diff patients, increasing the frequency of the room cleaning from once to twice a day, changing cleaning product and equipment, and using dedicated equipment for the individual C. diff patient.

Educating, training, and adding staff
Due to environmental services constraints at Hunterdon, the C. diff task force asked nursing and support staff to take on some cleaning responsibilities of medical equipment, which initially was not a welcome change.

"In addition to environmental services cleaning, we had to convince [nursing] staff that it was part of their role to clean," says Roye-Horn. "People thought cleaning wasn't their job and didn't have time for it. Gradually it became accepted and people are no longer surprised if someone asks them to wipe the stethoscope."

This initiative was successful because the task force sought buy-in from physicians on down, Nash says.

"Now we have physicians looking for wipes to clean stethoscopes, and NPs and clinical staff are making sure they are cleaning devices before they take them into another patient's room," she says.

The Jewish Hospital didn't ask clinical staff to take on any additional cleaning, but it did need their help in better preparation of patient areas for environmental services.

"It was important for nursing staff to assist environmental services by de-cluttering the patient's area," Wedig says. "If the nurses removed stray objects, environmental services could come behind them and do a through cleaning of those areas. The teamwork there was very important."

The Hunterdon task force made an appeal to hospital administration for more cleaning staff after it determined how many additional high-touch surfaces needed to be cleaned in the patient environment.

"We did work studies identifying the time difference it would take, and we were successful in achieving those FTEs because we demonstrated the cost avoidance dollars by reducing infections and saving the institution money," Nash says. "Neither of our departments are revenue-generating, so we have to demonstrate avoidances costs."

Nash has since hired seven FTEs dedicated to C. diff preventive cleaning.

Testing high-touch surface cleanliness
To ensure that the new cleaning processes work, both Hunterdon and the Jewish Hospital use rapid-testing technology to determine if surface areas are up to their new standards. 

"We test high-touch surface areas and can get quick feedback on whether they were actually hitting everything," Wedig says. "The environmental services staff really bought into the whole need for doing this because they understood how important the cleaning was."

The C. diff task force at Hunterdon decided to start using an auditing tool to benchmark the effort's success, in addition to the decreasing incidence rates. The team had to justify the tool's expense to hospital administration, but it quickly became clear to all parties that the cost was worth it.

"The additional cost of the auditing tool is well warranted because it gives staff the confidence they're doing a good job," Nash says. "We found our staff is engaged in the process; they want to know how they're doing and they love the feedback. They get involved in actual testing itself, and it's a wonderful complete circle to the approach that will help get C. diff under control for any facility."

Since the height of Hunterdon's NAP1 outbreak in 2004, the hospital has seen an 80% decrease in c. diff cases and continues to see a decrease each year.

At the Jewish Hospital, the C. diff incidence rate was 21.1 per 10,000 patient days in March 2010, beating the goal of 22.74. By the summer of 2011, the rate had fallen to 3.08. 

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This article appears in the March 2012 issue of HealthLeaders magazine.