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This presentation was delivered in session A2 of Quality Forum 2014 by: Barbara Holuboff Prior: Manager, Acute Care for Elderly (ACE) Units, Peace Arch and Surrey Memorial Hospital Fraser Health Elizabeth Lucia Clinical Nurse Educator, Acute Care of Elders, Surrey Memorial Hospital Fraser Health
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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
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