Expanding the C. difficile Infection Prevention Bundle to include Patient Hand Hygiene

Purpose:
The purpose of the study was to determine the effect of an expanded bundle approach to the prevention of Clostridium difficile (CD) disease in hospitalized patients.

Significance:
CD infections have contributed to increased lengths of stay, adverse outcomes such as colectomy and transfer to the ICU, an attributable mortality rate of 6.9% at 30 days after diagnosis (16.7% at 1 year) as well as an estimated healthcare cost of more than 3.2 billion dollars annually

Strategy and Implementation:
Interventions included 1) early detection of CD cases by toxin testing of any patient with onset of unexplained diarrhea, 2) electronic alerts on positive toxin results to nursing units to initiate barrier precautions with glove and gown use, 3) staff HH with soap and water as opposed to alcohol sanitizer, 4) extended duration of isolation for entire hospital stay, 5) staff and patient education on CD disease, and 6) cleaning of all patient rooms with a hospital approved cleaning product followed by sodium hypochlorite (bleach) to sanitize all high touch surfaces. A CD Prevention Team with representation from infection control, nursing, pharmacy, laboratory, housekeeping and an infectious disease physician, directed implementation of the bundle and case monitoring. In late 2008, the CD Prevention Team focused on interrupting fecal oral transmission by adding a patient HH intervention to the bundle to prevent CD infection.

Evaluation:
The rate of CD infection during the intervention period was 6.95 per 10,000 patient days (116 cases/166,838 patient days). In comparison, the prior year's FY09 rate was 10.45 with 164 cases/156,956 patient days. Application of a Chi-square test denoted statistical significance at p = 0.0009.

Implications for Practice:
In expanding the bundle, nursing and patient care staff focused on applying the basic bundle and at the same time encouraging the patient to perform HH prior to meals and at every other opportunity that was presented. Patients expressed positive responses to the invitation to wash their hands.