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Hygiene as a CDI Prevention Strategy

Hygiene as a CDI Prevention Strategy. November 7, 2013 Susan Louis, RN, CIC DICON Nurse Consultant. Objectives. Describe the significance of CD as an environmental contaminant List strategies for maintaining a cleaner environment

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Hygiene as a CDI Prevention Strategy

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  1. Hygiene as a CDI Prevention Strategy November 7, 2013 Susan Louis, RN, CIC DICON Nurse Consultant

  2. Objectives • Describe the significance of CD as an environmental contaminant • List strategies for maintaining a cleaner environment • Explain the role of hand hygiene and contact isolation in reducing the risk of CDI

  3. Resources • APIC Guide to the Prevention of Clostridium Difficile Infections 2013 • 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

  4. Clostridium difficile-infection (CDI) has grown from a sporadic and minor problem to a substantial threat to hospitalized patients in the United States during past years

  5. Pathogenesis and Epidemiology • C. difficile spores are ingested by patients. • These spores then germinate in the gastrointestinal tracts of patients in whom the colonic flora has been altered (usually, but not invariably) by recent antimicrobial therapy. • After C. difficile spores germinate in the bowel lumen, they proliferate as vegetative bacteria and produce toxins (toxin A and/or toxin B) that in turn cause clinical disease.

  6. Pathogenesis and Epidemiology • The vegetative cell typically dies within 24 hours outside the colon. • As the organism strives to protect itself from undesirable environmental conditions, it assumes its spore form. 1

  7. Hypothesis for Acquisition C. difficile acquisition Antimicrobial (s) Asymptomatic C. Difficile colonization CDI Hospitalization From Johnson S, Gerding DN. Clin Infect Dis. 1998;26:1027-1036

  8. Key Concepts • Transmission of CD occurs via a fecal-oral route so any activity that may result in movement of the organism into the mouth must be addressed as part of the prevention strategies. 2 • The two major reservoirs are infected humans and inanimate objects.

  9. Isolation Precautions • Contact isolation for diarrhea pending results • Ensure rapid reporting of test results • Use a private room • Use barrier precautions • Don gown and gloves before entering the room • Discard before leaving the room • Monitor compliance

  10. www.spice.unc.edu

  11. If Private Rooms are Limited • Consider closing the room off to other patients • Cohort patients with C. difficile together • Change PPE and wash hands between patients • Do not share equipment • Use spatial separation • Draw curtain between patients • Visual cue such as colored tape placed on the floor

  12. Personal Protective Equipment • Perform hand hygiene • Don gown and gloves before entering the room • Remove PPE before leaving the room • Hand hygiene is always the final step

  13. Transporting the Isolated Patient • Limit to medically necessary purposes • Patient should don freshly laundered clothing • Patient should use appropriate barriers to contain and limit shedding into the environment

  14. Transporting the Isolated Patient • The transporter should remove their PPE before leaving the room and wash their hands • Clean PPE should be donned to handle the patient at the transport destination • Communicate isolation status to receiving unit

  15. When is it Safe to Stop Isolation? • CDC/HICPAC recommends discontinuation of isolation when diarrhea resolves. 3 • Some experts recommend continuation for several days after diarrhea resolves. • Others recommend continuation until discharge.

  16. A Tiered Approach • Increase precautions based on local data • Cohort staff • Closing the affected unit to new admissions • Tighter visitation rules • Increase use of dedicated or disposable equipment • Alternate methods of disinfection (UV light, vaporized hydrogen peroxide)

  17. Prevention Demands Strict Hand Hygiene • Agents • Soap and water • antimicrobial soaps are not sporicidal. • Spores are rinsed away • Alcohol rubsare not effective in killing CD spores

  18. Soap and Water is Required…. • When hands are visibly soiled • After using the bathroom • Before eating

  19. Conflicting Guidance • There have been no studies in acute care settings that demonstrate an increase in CDI when alcohol hand rubs are used • The use of alcohol rubs have been shown to reduce the risk of MDRO • Alcohol rubs may reduce the risk of device-related infections

  20. Glove Use • Prevents hand contamination • Use even for brief encounters • Remove if integrity is compromised • After removal hands should be washed

  21. Family and Visitor Education • Provide a fact sheet to patient and family • What is CDI and how is it spread • Consider restricting for persons at high risk for acquiring CDI (on antibiotics or immunosuppressed). 4 • Gown and glove use • Environmental cleaning • Hand hygiene

  22. Educate Patients, Staff, and Visitors

  23. Patient Hygiene • Hand hygiene • Daily shower or bath • Clean gown • Clean bed linen

  24. Healthcare Worker Hygiene • Wear freshly laundered clothing • Always perform good hand hygiene • Before and after patient contact • Before eating use soap and water • When hands are visibly soiled use soap and water • After using the bathroom use soap and water • Follow standard precautions

  25. Work Restriction • HICPAC 1998 Guideline for Infection Control In Healthcare Personnel • Personnel with diarrhea should not report to work • Personnel with CDI may return to work when diarrhea resolves • There is no recommendation to test personnel prior to returning to work • Utilize good hand hygiene

  26. Environmental Contamination • The level to which the environment becomes contaminated is proportional to the severity of the disease in the patient. • In one study spores were found in 49 percent of the rooms occupied by patients with CDI.5

  27. Highly Contaminated Items • Rectal thermometers • Oral care equipment • Feeding supplies • Commodes • BP cuffs • Call buttons • Bedrails

  28. Avoiding the Spread of Germs via Equipment • Dedicate equipment • Clean and disinfect reusable equipment using a bleach cleaner

  29. Workstations on Wheels • Always clean hands before accessing the workstation • The workstation must be decontaminated before moving to another patient room • Cleanable keyboards should be evaluated • Develop a policy for cleaning frequency (i.e.; daily, after exposure to an isolation room, and when visible soiled.

  30. Privacy Curtains • Spraying with 3% hydrogen peroxide has been effective against Gram-positive organisms in the laboratory6 • Antimicrobial complex element compounds incorporated into the material has been effective against Gram-positive organisms in the labloratory7 • Should be changed with terminal cleaning and more often for long-term patients

  31. Cleaning/Disinfection Agents • Some hospital disinfectants may encourage sporulation. • Need a product that’s an EPA-registered sporicidal. • 10% sodium hypochlorite (4800 PPM) • High concentration of hydrogen peroxide • Cleaning (with a detergent) is critical for optimal disinfection to occur. • Provide appropriate contact time.

  32. Educate Environmental Workers • C. difficile can persist for months • There is increased risk for subsequent patients • Educational programs directed at staff responsible for cleaning have been shown to be effective in reducing environmental contamination with CD8

  33. Improved Rates of Cleaning9

  34. Monitoring Methods • Direct observation • Swab cultures • Agar plates • ATP Bioluminescence swabs • Fluorescent markers

  35. UVM Protocol

  36. Delineation of Responsibility • EVS workers are rarely assigned the responsibility of cleaning critical patient care equipment. • These types of patient care equipment are typically cleaned by nurses or by special equipment technicians. • Policy should delineate responsibility and proper agent for each type of equipment.

  37. Operating Rooms • Communicate need for Contact Precautions • Remove unnecessary equipment/supplies • Consider taking patient straight back • Everyone in room needs to be gowned and gloved • Consider recovering patient in the OR • Thoroughly disinfect the room and equipment

  38. Skilled Nursing Facilities • The 2009 CMS F441 interpretive guidelines states, “Transmission-bases precautions are maintained for as long as necessary to prevent the transmission of infection. It is appropriate to use the least restrictive approach possible that adequately protects the resident and others. Maintaining isolation longer than necessary may adversely affect psychosocial well-being. The facility should document in the medical record the rationale for the selected transmission-based precautions.”

  39. Care Plan Considerations for the SNF Resident • Bowel control • Reliability to perform hand hygiene • Personal hygiene • Ability to comprehend instructions

  40. Summary • C. difficile contaminates the environment and remains for long periods • Hand hygiene reduces the risk of spreading CD from person to person • Reducing the amount of contamination in the environment reduces the risk of spreading CD

  41. Summary • Educating patient and family promotes compliance to the principles of hygiene • Adherence to contact isolation precautions protect contamination of the hands and clothing and reduces the risk of spreading CD • Policies should define cleaning practices and compliance should be monitored.

  42. References • 1, 2, 4. 2013 APIC Guideline to Prevention of Clostridium difficile Infection • 3. Seigel JD, Rhinehart E, Jackson M, Chiarrello L and the HICPAC 2007. Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. • 5. Samore MH, Venkataraman L, DeGirolamiPC, ArbeitRD, Karchmer AW. Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 1996;100(1):32-40. • 6. Neely AN, Maley MP. The 1999 Lindberg Award. 3% hydrogen peroxide for the gram-positive disinfection of fabrics. J Burn Care Rehabil1999 Nov-Dec;20(6):471-477. • 7. Schweizer M, Graham M, Ohl M, Heilmann K, Boyken L, Diekema D. Novel hospital curtains with antimicrobial properties: a randomized, controlled trial.Infect Control HospEpidemiol2012 Nov;33(11):1081-1085. • 8. Eckstein B, Adams D, Eckstein E et al. Reduction of Clostridium difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infectious Diseases 2007; 7:61 • 9. Carling PC, Parry MM, Rupp ME, Po JL, Dick B, Von Beheren S; Healthcare Environmental Hygiene Study Group. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control HospEpidemiol. 2008 Nov;29(11):1035-41

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