The C. difficile workgroup is co-led by Value Institute Performance Improvement Consultant Victoria Adams, CSSBB, Hospital Epidemiologist Michael Calderwood, MD, MPH, and Infection Preventionist Megan Read, MPH, MLS (ASCP), CIC.

Thanks to the hard work of the C. difficile workgroup and process measures put in place over the past year, Dartmouth-Hitchcock (D-H) is not only meeting its 15 percent reduction goal for this Hospital Acquired Condition (HAC) but exceeding it. There were zero hospital-acquired C. difficile infections in July and only three in August. Additionally, the hospital went 47 days without a C. difficile infection this summer; the previous record was 24 days.

The C. difficile workgroup is co-led by Hospital Epidemiologist Michael Calderwood, MD, MPH, Infection Preventionist Megan Read, MPH, MLS (ASCP), CIC, and Value Institute Performance Improvement Consultant Victoria Adams, CSSBB. “This is a huge accomplishment that has taken the entire organization working collaboratively to achieve,” says Read. “Each and every individual that sets foot in this hospital has the ability to impact the transmission of C. difficile.”

“Our target rate is five or less cases a month in order to meet our 15 percent reduction goal for fiscal year 2018, so we’re on track,” says Adams. “Last year, we started with 11 cases in July. So, this year is a tremendous improvement.”

Calderwood also praised D-H staff who are involved in the C. difficile reduction work. “A lot of work has gone into this,” he says. “Some of the key areas we’ve been focusing on seek to break transmission in the hospital setting. This includes things like improved hand hygiene, early identification of patients who might have C. difficile infection to make sure they’re in a private room and on appropriate contact precautions, working with the Environmental Services team to audit and provide education on room cleaning, and working with all members of the health care team on cleaning items, like stethoscopes, that can transmit pathogens from one room to the next.”

Calderwood notes that the workgroup hopes to get even more hospital employees involved in this important infection prevention work by establishing a C. difficile Prevention Committee. The first meeting was held in September, and Calderwood says, “As part of this multi-disciplinary committee, we’re looking for strong physician representation, but we also want membership from across the care continuum. This is going to take an effort by the entire institution. Infection prevention is everyone’s responsibility.”

In addition to a 15 percent reduction in C. difficile, Calderwood says they also want to reduce high-risk antibiotic use at D-H by 10 percent. “That’s a big part of our work moving forward, and that will require physician buy-in and behavioral change,” Calderwood says.

Changes that have been implemented

Using the DMAIC methodology (Define, Measure, Analyze, Improve, Control), Adams says the workgroup looked at “what was really happening across the broad spectrum of everything that impacts C. difficile.” This process helped them to understand the impact of improvement work over the past couple of years and to address and prioritize potential gaps. Among the changes that have recently been implemented:

• New C. difficile Testing Policy: To avoid unnecessary lab testing, a new policy was developed which only permits testing when patients have clinically significant diarrhea and at least one other sign or symptom of a C. difficile infection. If specific testing criteria are not met, C. difficile tests will be canceled (if there isn’t a compelling reason to proceed with testing). Around 10% of patients are colonized with C. difficile so selecting the most appropriate patient population for C. difficile testing directs treatment to patients with true C. difficile infections.
• An increased focus on antibiotic utilization: For every hospital acquired C. difficile infection, all antibiotics used prior to that infection are reviewed for appropriateness.
• Hand Hygiene: Continued focus on hand hygiene education and hand hygiene compliance monitoring and feedback.
• Education: Infection Preventionists (IPs) visit with all inpatients with C. difficile and provide basic education on C. difficile. The IPs also visit with the patient’s care team and answer any questions they may have. This information is summarized in a consult note. Additionally, the IPs perform observations to ensure hand hygiene is being performed appropriately and the appropriate PPE is available to staff and being worn. As part of this effort, the hospital has standardized isolation carts to ensure availability of proper PPE.
• Cleaning/Disinfection: The low-level disinfection policy and procedure were updated and the workgroup will soon be rolling out a document that clarifies cleaning responsibilities and minimum cleaning frequency expectations.
• Environmental Services (EVS) has made a number of changes, including regularly replacing cubicle curtains, daily bleach cleaning of all Contact Precaution rooms and continued quality checks on patient rooms to ensure a thorough clean.
• A hydrogen peroxide vapor cleaning/disinfecting technology is being introduced in fiscal year 2018. This technology is designed to be used after Environmental Services performs their routine cleaning after patients are discharged. It will provide an additional level of cleaning/disinfection of patient rooms.

“It’s not just about meeting a reduction goal; it’s about providing the safest care possible to our patients. Patients come to the hospital to heal, not to acquire a preventable infection,” says Read.