Background: Clostridium difficile infections (CDI) is the most common cause of healthcare-associated infections in the United States. CDI accounts for 15%- 25% of all cases of nosocomial diarrhea. CDI is associated with significant adverse outcomes such as higher inpatient mortality rate, a longer length of hospital stays and increased hospital costs. The incidence of Hospital-acquired CDI has been trending upwards over the recent years. The Center for Disease Control estimated that the incidence of hospital-acquired CDI was above 500,000 cases in 2015, and the impact of CDI is regarded as one of the highest threats. Englewood health (EH) was found to have a higher rate of hospital-acquired CDI with standard infection ratio (SIR) of 1.336 compared to the average SIR of 0.906 in the state of New Jersey between 2016 to 2017.
Methods: We reviewed 40 charts of previous CDI cases and completed a fishbone diagram identifying contributors to this problem. The current process of how CDI cases were diagnosed and managed was reviewed with an emphasis on addressing areas of improvement. We designed a process map for how CDI cases ideally should be diagnosed and managed. We listed possible interventions and reviewed each utilizing an effort vs. impact chart, which allowed us to focus on an idea that will lead to the biggest impact with the least amount of effort. QI methodology was adopted incorporating the Plan, Do, Study, Act (PDSA) cycle which includes PDSA cycle 1 and PDSA cycle 2. Pre-intervention data was obtained by sending a survey to internal medicine residents to gauge their knowledge of clostridium difficile transmission, the utility of appropriate personal protection equipment (PPE) and hand hygiene practice. In PDSA cycle 1, a total of 42 Internal medicine residents were educated on hand hygiene and PPE either during regular scheduled didactic conferences or via an individual meeting with a presentation and discussion. Both pre and post questionnaire surveys were assessed. In PDSA cycle 2, a total of 17 hospital transporters. were given educational lectures with additional time for a post-lecture Q&A. The lectures included modes of CDI transmission, the biology of clostridium difficile spores, the emphasis of hand hygiene and PPE adherence, an introduction of CDI symptoms.
Results: Overall there was an improvement in hand hygiene practice and knowledge of CDI among medical residents, coincidentally, In our pre-survey, half of the residents reported that they previously encountered patients who are infected with CDI without proper PPE. This decreased to only 18% post-education. For the proper way to wash their hands to destroy Clostridium difficile spores, 78% of residents were compliant, which was improved from 50% pre-intervention. Only 48% of residents were confident in their knowledge of when to order CDI tests compared to 88% post-intervention. In addition, 56% of residents knew the biology of clostridium difficile prior to the educational sessions with an increase to 72% post-education. The test results from pre vs post-education on hospital transporters were significantly improved from an average score of 41 to 85%. During our QI project, hospital-acquired CDI in EH decreased by 16 %.
Conclusions: Our QI project interventions contributed to the EH control of Hospital-acquired CDI with a 16% decrease in a one-year window. Controlling and decreasing CDI rate is challenging and there is a need for consistent collaboration between different departments and healthcare providers.