SummaryFaced with an increase in the number of Clostridium difficile (commonly known as C. difficile) infections, Florida Hospital Tampa implemented a comprehensive program to reduce environmental transmission of the bacterium. Key program elements include contact isolation for suspected and confirmed cases, use of a bleach cleaning solution on all potentially contaminated surfaces, vigorous hand hygiene, distribution of educational information to patients and visitors, use of daily automated reports on the status of all infected patients, formulary restrictions on use of certain antibiotics known to increase risk of infection, and inspection of discharge rooms. The program led to a 66-percent reduction in the monthly rate of C. difficile cases during the 2-year study period, with further reductions after the study ended.
See What They Did for updated information on key program elements. (Updated June 2014.)Moderate: The evidence consists of a before-and-after comparison of the hospital's monthly C. difficile infection rate.
Developing OrganizationsUniversity Community Hospital
Date First Implemented2003
Problem AddressedC. difficile infections represent a rapidly growing problem that poses severe health risks for hospitalized patients, including the potential for severe diarrhea, dehydration, sepsis, and, in rare cases, death. Hospital cleaning measures that are effective against many other bacteria often are ineffective against C. difficile.
- Sharp rise in number of infections: The number of C. difficile infections has risen sharply in recent years, particularly in hospitalized patients (for whom infection rates have risen approximately 25 percent per year since 2000).1 A recent study of 648 U.S. hospitals found a prevalence rate of 13.1 per 1,000 inpatients; the study's authors estimate that on any given day, about 7,200 hospitalized patients are treated for C. difficile infection.2
- Leading to severe health risks, high costs: Symptoms include watery diarrhea (often lasting for days), fever, loss of appetite, nausea, and abdominal pain. Severe cases can lead to colitis, perforations of the colon, sepsis, and, in some cases, death.3 Estimated mortality is 4.2 percent, while the costs of treating each case is estimated at $4,475.4
- Difficult to stop from spreading: In hospitals, C. difficile infection most commonly begins as an unintended consequence of treatment with antibiotics for other infections. Once present, C. difficile easily spreads from patient to patient, with many cases resulting from hospital staff spreading bacteria from their hands onto medical equipment or directly to patients. Reducing patient-to-patient transmission requires diligence because spores from the bacterium can survive for months on surfaces such as floors, furniture, sinks, bedpans, toilet seats, and stethoscopes, and alcohol-based hand gels do not inactivate the spores.4
Description of the Innovative ActivityFlorida Hospital Tampa implemented a comprehensive program to reduce environmental transmission of the bacterium that causes C. difficile infection. Key program elements include contact isolation for suspected and confirmed cases, use of a bleach cleaning solution on all potentially contaminated surfaces, vigorous hand hygiene, distribution of educational information to patients and visitors, use of daily automated reports on the status of all infected patients, formulary restrictions on use of certain antibiotics known to increase risk of infection, and inspection of discharge rooms.
- Contact isolation for suspected and confirmed cases: The rooms of all patients suspected of or confirmed as having a C. difficile infection become contact isolation rooms. Patients in isolation have a private room with a large isolation sign outside the door that includes reminders to staff and visitors about proper hygiene procedures (e.g., wear gloves, wear gown, wash hands before and after seeing the patient). Visitation is limited, and anyone who enters the room must follow these procedures.
- Use of bleach cleaning solution: As part of the hospital's disinfection protocol, staff use a bleach solution (known as 10 percent hypochlorite disinfection) on all potentially contaminated surfaces at least once a day. Frequently handled equipment is cleaned several times a day, and reusable patient care equipment is cleaned and disinfected after each patient use. When one patient on a unit is infected, staff use the solution on all surfaces in that patient's room. When two or more patients on a unit are infected, staff use the solution on all surfaces and reusable medical equipment in all of the patient rooms and across the entire nursing unit. To maximize the solution's effectiveness when spraying reusable medical equipment, the hospital uses dual-chamber spray bottles that combine the bleach and water during spraying.
- Hand washing with soap and water after all patient contact: The disinfection protocol requires staff to wash their hands with soap and water before and after all patient contact. Alcohol-based solutions cannot be used because they do not always inactivate C. difficile spores.
- Educational materials for patients and visitors: Infected patients and their visitors receive a one-page handout (written at a fifth-grade level) that explains what C. difficile is, how it is transmitted, and what precautions patients and visitors should take to avoid further transmission.
- Use of automated reports: When a patient tests positive for C. difficile infection, key information on the case is entered into the hospital's electronic record system (e.g., the patient's identification information and his or her room number and unit). Staff enter additional information as it becomes available, such as the results of lab tests indicating the strain of C. difficile and whether the patient tests positive or negative after receiving a regimen of antibiotics to counter C. difficile. Each day, the system generates a report on all current C. difficile cases, which is disseminated to all nursing directors, nurse leaders, and the environmental services director. This "real-time" information is used in a number of ways to maximize the program's effectiveness:
- Isolation rounds: Nurse leaders use the report as the basis for isolation rounds, which consist of visiting each patient room and ensuring that the isolation sign is on the door, an isolation card is on the patient's chart, and that the isolation protocol is being followed. If a patient tests negative after completing treatment with an antibiotic, contact isolation ends, avoiding unnecessary expense.
- Prompts for housekeeping staff: The environmental services director checks the report each day to ensure that each housekeeper is aware of units and patient rooms that need the bleach disinfection protocol.
- Information for ancillary staff and physicians: A copy of the report is kept on a yellow clipboard in a standard location at the unit nurse's station for reference, allowing ancillary department staff and physicians to easily access it as needed.
- Information for infection control specialists: Infection control specialists use the report to identify clusters of new cases that might indicate that staff are not following the disinfection protocol. They also review the results of the DNA typing tests to identify any new strains that may have developed. These results are also sent to the Centers for Disease Control and Prevention, which tracks the spread of different strains.
- Performance measurement and feedback: The reports are used to calculate the hospital's monthly infection rate, with results being circulated throughout the hospital and posted in prominent places visible to staff as a motivational tool.
- Formulary restriction to prevent overuse of certain antibiotics: The hospital has an Antimicrobial Stewardship Committee that reviews physician prescribing practices and, according to a protocol, works with doctors who may be prescribing antibiotics inappropriately.
- Inspection of discharge rooms: The infection control department added inspection of discharge rooms for readiness and adenosine triphosphate (ATP) monitoring in collaboration with the Environmental Services Leadership team to ensure proper disinfection of the patient room environment. (Updated June 2014.)
Context of the InnovationFlorida Hospital in Tampa, FL, is a 431-bed tertiary care facility. In January and February 2003, the infection control department noted a sudden increase in the number of patients with C. difficile infections. A preliminary investigation revealed cross-contamination of several patients in one room as well as room-to-room transmission to patients adjacent to C. difficile–positive patients. Department leaders began researching measures they could take to control the spread of C. difficile and prevent a larger outbreak in the facility. The review yielded little comprehensive information, so the hospital began developing its own program.
ResultsDuring a 2-year study period, the hospital's monthly C. difficile infection rate decreased by 66 percent, from a high of 1.33 per patient day in February 2003 to 0.45 in December 2004. (The daily infection rate is the number of patients with infections on that day divided by the total number of hospitalized patients that day, multiplied by 1,000.) Since that time, the rate decreased by an additional 55 percent, to 0.2 per 1,000 patient days. Based on the reduction in the number of patients with C. difficile, the hospital estimates that it saved $598,000 during the program’s first year, $234,000 in the second year, and $78,000 in the third year. As of June 2014, the hospital is at an 87-percent reduction in healthcare-associated infection C. difficile infections.Moderate: The evidence consists of a before-and-after comparison of the hospital's monthly C. difficile infection rate.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Task force formation: The hospital formed a task force to address the issue. Team members included the infection control director, infection control practitioners, nurse leaders, nurse directors, physicians, and the environmental services director. Initially, the task force met every day. As the infection rate dropped, meetings became less frequent and now occur monthly.
- Identification of objectives: The task force identified three primary objectives: identify the etiology of the hospital's C. difficile cases, develop an effective protocol to prevent the transmission of the infection, and decrease the overall incidence of C. difficile cases.
- Research: Although a literature review and calls to other hospitals and governmental agencies did not yield any comprehensive programs for preventing C. difficile transmission, it did produce valuable information the task force used in developing its own program, including, for example, information on common modes of transmission, ways to kill the bacterium, and the role of DNA typing. The task force used this information to develop the infection control protocol and to produce printed educational material for staff, patients, and visitors.
- Staff training: In the spring of 2004, nurse leaders ran 45-minute training sessions for all employees who have contact with patients (including doctors, nurses, and cleaning staff). Sessions focused on the staff's role in reducing transmission and identifying possibly infected patients as early as possible (e.g., by knowing which antibiotics put patients at risk for infection and that multiple loose stools with a foul odor are often a sign of C. difficile infection). These sessions, offered in English and Spanish, were intentionally kept small (with four to six participants) to ensure that staff fully understood the material and could ask questions. All relevant staff initially attended during the program's first few months, and new employees receive the training as part of their orientation.
Resources Used and Skills Needed
- Staffing: The program did not require the hiring of any additional staff; everyone participates as part of his or her normal job responsibilities.
- Costs: The program does not require significant spending, because it largely involves inexpensive resources already available at the hospital (e.g., bleach, soap, gloves, gowns). Record keeping related to C. difficile was integrated into the hospital's existing electronic records system. One additional expense is for DNA testing of those who test positive for a C. difficile infection, which runs roughly $100 per patient. In 2003, the hospital ran 15 of these tests; that number has fallen in subsequent years due to the decline in the infection rate.
Funding SourcesThe program's cost is covered by the hospital's internal operating budget.
Tools and Other ResourcesThe one-page handout for patients and visitors on C. difficile is available via e-mail from the program developer.
Getting Started with This Innovation
- Emphasize collaboration: All types of staff should be represented on the task force that develops and implements the infection control measures, including infection control specialists, doctors, nurses, and the environmental service director.
- Stress timeliness: Because C. difficile can spread quickly, the hospital's internal infection control surveillance system must be based on "real-time" information disseminated daily.
- Point out risk to employees: To encourage staff buy-in and compliance, highlight during training the risk of infection to staff members if proper infection control procedures are not followed.
Sustaining This Innovation
- Publicize results: Posting the monthly infection rate in prominent places helps to keep infection control a priority.
- Maintain zero tolerance for backsliding: Infection control staff who observe staff violating the hygiene protocol should point out the error immediately. Egregious violations should lead to disciplinary measures and, if necessary, dismissal.
Spreading This InnovationAfter the publication of a study on the program, the hospital received a
number of inquiries from other hospitals interested in improving their
procedures for controlling C. difficile, including one in Germany.
Contact the InnovatorJacqueline Whitaker, RN, MS, LHCRM, CPHQ, CIC
Director of Infection Control
Florida Hospital Tampa
3100 East Fletcher Ave.
Tampa, FL 33613
Innovator DisclosuresMs. Whitaker has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesWhitaker J, Brown BS, Vidal S, et al. Designing a protocol that eliminates Clostridium difficile: a collaborative venture. Am J Infect Control. 2007;35(5):310-4. [PubMed]
McDonald LC, Owings M, Jernigan DB. Clostridium difficile
infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis. 2006;12:409-15. [PubMed]
Jarvis W, Schlosser J, Jarvis A, et al. National point prevalence of Clostridium difficile
in US health care facility inpatients, 2008. Am J Infect Control. 2008;37(4):263-70. [PubMed]
Whitaker J, Brown BS, Vidal S, et al. Designing a protocol that eliminates Clostridium difficile
: a collaborative venture. Am J Infect Control. 2007;35(5):310-4. [PubMed]
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Original publication: October 14, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 12, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.