Community Hospital Network Leverages Best Practices to Fight Spread of Clostridium difficile

When it comes to fighting infection, there is power in numbers, and the Duke Infection Control Outreach Network (DICON), a collaboration between Duke University Medical Center (DUMC) and 39 community hospitals spanning from Northern Virginia to Atlanta, is working to prove that. The network exists to help hospitals with limited resources develop state-of-the-art infection control programs and to give institutions with more sophisticated programs access to comparative statistics to support their infection control efforts. DICON is focused on improving infection control programs by compiling data on healthcare-acquired infections (HAIs) at member hospitals, identifying trends and areas for improvement and providing ongoing education and leadership to community providers. 

Controlling infections is a struggle for hospitals everywhere. Achieving this goal becomes more complicated each year as new technologies and procedures create new infection control problems. Antimicrobial resistance has increased to an alarming level and tighter budgets and staff cutbacks make it harder for many hospitals to meet increasingly complex infection control regulations. The converging impact of these trends is particularly unfortunate and ill-timed at community hospitals, where infection control programs are usually managed by nurses with numerous additional responsibilities. DICON helps address these issues by advancing efforts that improve quality of care, enhancing patient safety, and minimizing costs by using evidence based approaches to infection control.

With Clostridium difficile (C. difficile) rates recently surpassing methicillin-resistant Staphylococcus aureus (MRSA) infections in hospitals, DICON is focusing its efforts on developing new protocols and procedures to help combat the spread of C. difficile, which is now the most common HAI. C. difficile causes a wide variety of symptoms, from diarrhea to more serious life-threatening intestinal disease.  Research shows that when healthcare facilities proactively identify where and when infections are likely to occur and take concrete steps to prevent them, some infection rates have dropped more than 70 percent in hospitals.

Shared Responsibility

Preventing the spread of C. difficile is an all hands on deck effort at our medical center, says Deverick J. Anderson, MD, MPH, assistant professor in the Division of Infectious Diseases and Department of Medicine at DUMC and co-director of DICON.  Infection control physicians, fellows, nurses and environmental services work together to identify practices and protocols that will improve patient care and reduce unnecessary medical supply costs, additional inpatient days, unreimbursed readmissions and related causes of patient dissatisfaction. When problems in infection control or patient safety practices or protocols are identified, action plans are developed that are designed to both correct the immediate problem and prevent its recurrence.

Reporting & Training 

Protocols range from using specific cleaning products to following proper hand hygiene guidelines.  Each protocol is important but each step also adds a layer of complexity to the prevention program so we put tracking systems in place to measure the effectiveness of our efforts and to ensure that staff is adhering to protocols, Anderson adds. 

In addition to tracking systems, staff training is paramount to the success of DUMCs C.difficile prevention program.  The medical center in conjunction with DICON provides staff with a range of training modules, including online courses, videos and toolkits, to supplement in-person seminars.  During training, its critical to obtain buy-in from staff on cleaning methods, protocols and products, Anderson says. 

Proactive Identification

 DUMC is taking a new approach to contact precautions, or keeping symptomatic patients in isolation, to help better control the spread of C. difficile.  According to Anderson, patients who were asymptomatic and no longer on therapy could previously be released from isolation. Based on recent data showing that some asymptomatic patients continued to spread C.difficile to the environment, DUMC now takes steps to ensure patients remain under contact precautions for the duration of their hospital stay.

Durham Regional Hospital, which is part of DICON, is leveraging a new contact precautions protocol as well. The hospital uses a syndrome-based isolation protocol, meaning at the first sign of a potential infection, patients are moved into isolation. For instance, patients with diarrhea are presumptively moved into isolation until it is proven they do not have a C. difficile infection. 

Choosing the Right Tools

Last year, DUMC changed its environmental cleaning protocol.  Instead of using quats (quaternary ammonium compounds), the medical center decided to use bleach to decrease the amount of potential contamination within the hospital. One of the primary reasons we switched from quats to bleach is because we wanted to help prevent the spread of C. difficile. We also wanted to help prevent norovirus outbreaks in our hospital. Bleach is effective against both C.difficile spores and norovirus so we believe the switch was a reasonable and appropriate intervention, Anderson says. 

DUMC uses bleach in all of its patient care areas to help decrease the amount of potential contamination within the hospital.  We not only use bleach in patient rooms, but we also use it in radiology and operating rooms as well, Anderson says.  Bleach is the way we clean at Duke. Some other hospitals in the DICON network, including Durham Regional Hospital, use bleach as well.

In some high-risk areas of the hospital, such as common areas, patient play rooms and pediatric wards, DUMC also uses UV light technology to kill C.difficile spores. The technology emits a specific dose of UV light to decontaminate the room.  According to Anderson, using this device can be challenging because the UV light takes approximately 15 to 50 minutes to kill C. difficile spores, which adds to room turnover time. 

Overall, hospitals in our network are trying to gain a better understanding of how much C. difficile is coming from the community versus how much is actually being created in the hospital, Anderson says.  Its a difficult issue to grasp, but knowing this information will help us continue to improve our systems and practices and better measure our efforts to control the spread of C. difficile.