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C. Difficile taking a toll on healthcare system

A formidable foe

Collaborative efforts target C. diff after infections hit 'historically high levels'


By Maureen McKinney
Posted: October 27, 2012 - 12:01 am ET
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Even as hospitals, not-for-profit groups and government agencies tout the successes from their efforts to prevent healthcare-associated infections, rates of Clostridium difficile, a highly contagious and dangerous bug, have continued to grow.

In March, the Centers for Disease Control and Prevention issued a sobering report stating that C. difficile infection levels had risen to “historically high levels,” and related hospital stays had tripled during the past decade. Such infections are linked to 14,000 deaths and more than $1 billion in additional healthcare costs in the U.S. each year, according to the CDC.

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One of the major contributing factors to the spike in infections, experts say, is the misuse and overuse of antibiotics, which rid the gut of protective bacteria, allowing C. difficile to flourish and making patients—particularly older people—much more vulnerable to illness. Also, the C. difficile spore is easily transmitted and is much more difficult to thoroughly clean from surfaces than other germs.

“With all that said, we have good evidence that it's preventable,” says Dr. L. Clifford McDonald, a medical epidemiologist at the CDC.

Although high C. difficile rates have persisted nationally, some state agencies and hospitals have seen impressive drops, bolstered by specialized infection-control practices, antimicrobial stewardship campaigns and collaboration among acute-care and long-term-care settings, McDonald says.

One such facility is 209-bed Jewish Hospital, part of 29-hospital Catholic Health Partners, both based in Cincinnati. In spring 2009, galvanized by high C. difficile incidence rates—25.27 per 10,000 patient days versus the average rate of 7.4 per 10,000 patient days among hospitals reporting infection data to the CDC in 2010—the hospital formed a multidisciplinary task force led by the hospital's infection preventionist.

The group, which included nurses, physicians and environmental services personnel, focused its efforts on standardizing clinical care, curbing inappropriate use of broad-spectrum antibiotics and improving environmental cleaning services. By March 2010, a year into the program, the hospital's C. difficile rates had fallen by more than 16%. Since then, rates have continued to fall, plummeting more than 80% from the baseline.

'A complex issue'

“C. difficile is definitely on hospitals' radar,” says Diane Jacobsen, an epidemiologist and a director at the Cambridge, Mass.-based Institute for Healthcare Improvement, “and there is a strong commitment to reducing rates and being aware of the problem.”

But Jacobsen, who led past IHI initiatives focused on addressing C. difficile, says tackling the issue has at times proved difficult because of a number of factors, including poor communication during transitions of care.

“It's a complex issue,” she says. For instance, some hospitals don't have electronic health-record systems in place that can ensure lab results are transmitted quickly and additional precautions are taken—an added safeguard that's particularly important as patients move from unit to unit or are discharged.

Also, many hospitals are still working to implement antimicrobial stewardship programs, whose purpose is to ensure antibiotics are used appropriately and are stopped when indicated.

Just making sure a physician or nurse has ready access at a patient's bedside to information about the type of infection, the antibiotic, and its duration and dosage can be very effective, Jacobsen says.

Some hospitals have configured their EHR to deliver that information at the point of care, while other facilities still rely on paper documentation, she adds. Some hospitals have instituted antibiotic “time-outs” during which hospitalists, nurses and other members of the care team take a moment during rounds to review antibiotic usage and determine whether a more narrow-spectrum drug can be prescribed or whether antibiotic treatment can be discontinued altogether.

According to the CDC, many of the most successful C. difficile-prevention initiatives to date have been led by local and state health departments.

“C. difficile infections are usually a regional problem since patients transfer back and forth between facilities, such as from nursing homes to a hospital, which allows the disease to spread,” according to the CDC's website. “Health departments have the ability and authority to work with many types of healthcare facilities, and therefore have a unique opportunity to coordinate comprehensive prevention programs in their state or area.”

One such effort, the Massachusetts CDI Prevention Collaborative, headed by the state's health department, saw significant reductions in C. difficile. Launched in 2010 with CDC funding set aside in the American Recovery and Reinvestment Act of 2009, the 20-month collaborative included 27 participating hospitals.

From the outset, the effort focused on educating frontline staff about the harms caused by C. difficile and the ways in which each of them could work to prevent infections, says Paula Griswold, executive director of the Massachusetts Coalition for the Prevention of Medical Errors, which worked as a contractor on the project.

“That turned out to be a very powerful technique,” Griswold says. “It was very rewarding for every staff member, from environmental services to dietary, to know that their knowledge and ideas were central to the solutions we developed.”

The collaborative's best practices—including more rigorous cleaning and disinfection practices, increased contact precautions, enhanced antimicrobial stewardship and improved hand hygiene—led to a 25% drop in C. difficile among participating hospitals. If those results were replicated in all Massachusetts hospitals, 1,050 infections and $6.3 million in additional healthcare costs could be avoided, according to estimates from the Massachusetts coalition.

C. difficile spores
C. difficile spores are especially difficult to eradicate. Through team-based efforts, hospitals are making progress in cutting infection rates.
Through its work in the collaborative, Harrington Hospital, a 114-bed facility in Southbridge, Mass., ramped up its early identification protocols and implemented new cleaning guidelines tailored specifically for difficult-to-kill C. difficile. The hospital also instituted mandatory education sessions about the bug for all staff members, says Sue Valentine, an infection preventionist at the hospital whose dedication to the cause once led her to dress up as a C. difficile spore in a successful attempt to win an educational grant from a vendor.

Another CDC-funded effort, the Illinois CDI Prevention Collaborative, led by the Illinois Department of Public Health, emphasized staff education, lab alerts, more thorough cleaning with bleach-based disinfectants, hand hygiene and other evidence-based practices to achieve significant drops in C. difficile.

In keeping with national trends, statewide rates of C. difficile had nearly doubled from 1999 to 2009, says Mary Driscoll, the department's chief of patient safety and quality.

“We thought we had an excellent opportunity to do something about it,” she says.

The collaborative kicked off in early 2010 with an initial cohort of 11 Chicago-area hospitals, including 313-bed Swedish Covenant Hospital in Chicago and 683-bed Advocate Christ Medical Center in Oak Lawn. Hospital-onset C. difficile rates fell by more than 15% among that group following the project. Among a second cohort of nine hospitals, in central and southern Illinois, infection rates fell by 26%.

And since that project ended in September 2011, the Public Health Department has launched the Illinois Campaign to Eliminate Clostridium Difficile—or ICE C. diff—a larger-scale initiative involving acute-care and long-term-care facilities. So far, the campaign, which works to disseminate the lessons learned during the initial collaborative, has enrolled 270 facilities, says Erica Abu-Ghallous, the departments' coordinator for healthcare-associated infections.

McDonald of the CDC says he expects to see more success at reducing C. difficile rates as hospitals share best practices and implement health information technology systems. And on Jan. 1, 2013, the CMS will begin to collect data on hospitals' incidences of C. difficile for use in its fiscal 2015 hospital inpatient quality-reporting program.

Under the CMS' hospital inpatient quality-reporting program, hospitals voluntarily submit data on a set list of quality measures or they receive a 2% reduction in their annual payment update. Quality data are posted on Hospital Compare, the CMS' consumer website, and after one year, measures are eligible for inclusion in the agency's value-based purchasing program.

Such programs will drive further awareness of the problem and spur new improvement initiatives, McDonald predicts.

“I'm hopeful that as we see greater transparency, we will see that this is a winnable battle,” he says.


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