by Janet H. Keen, RN, MS, CIC

Piedmont Hospital in Atlanta has reduced the Clostridium difficile infection (CDI) rate by 21% in one year using measures recommended by APIC and other infection prevention authorities. Our aggressive approaches to reduce CDI resulted in a decline at Piedmont Hospital despite an increase in many other Southeastern hospitals. Initiatives led by the Infection Prevention Department spurred hospital-wide involvement that included nursing staff, medical staff, environmental services, pharmacy, the emergency department, the education department, as well as supply chain and clinical quality experts. I’ll summarize some of the most important initiatives.

We believe a key factor in reducing CDI has been to empirically isolate any patient with diarrhea or incontinence even before testing for Clostridium difficile is ordered.

Infection Preventionalists and the Nursing Education Council conducted short educational sessions to stress the importance of identifying patients who may have a CDI and reminding the RNs to promptly place symptomatic patients on Contact Precautions. Registered Nurses and MDs were instructed to initiate precautions for any patient with diarrhea or bowel incontinence or if testing for Clostridium difficile was ordered. Emergency Department RNs and MDs have played an important role as they initiate contact precautions from the patient’s point of entry into our system. Registered Nurses are empowered to immediately initiate the Contact Precautions. However, precautions may be discontinued only after the patient has been evaluated by an Infection Preventionalist to be sure that symptoms have resolved and the patient has received appropriate treatment.

Leaders in environmental services (EVS) have partnered with the Infection Preventionalists to develop practical ways to optimize environmental cleaning and disinfection. We found that there was lack of clarity in "who cleans what." A multidisciplinary group met to define cleaning roles for environmental services, nursing staff, and ancillary departments such as Respiratory Care and the GI procedural area. We photographed typical patient rooms and equipment and then labeled the illustrations with cleaning responsibilities. We changed to bleach disinfection in the rooms of patients with Contact Precautions for diarrhea or suspected Clostridium difficile. All patient rooms are cleaned with bleach at the time of patient discharge. In addition, new EVS employees are trained in effective cleaning techniques using an ATP bioluminescence measuring device made by Hygiena. Supervisors use ATP testing to check the effectiveness of cleaning and disinfection at the time of discharge cleaning as well. The Hygiena is easy to use and gives real-time feedback in an easy to understand manner. Piedmont Hospital has expanded use of the Hygiena and we are using bioluminescence ATP methods now to train operative staff in effective cleaning methods.

Illustration 1: Hospital Acquired Infections

A screen shot from the Piedmont Hospital public website illustrating voluntary disclosure of Piedmont Hospital’s Clostridium difficile infection rate. (http://www.piedmonthospital.org/oth/Page.asp?PageID=OTH000276)

Hand hygiene and isolation compliance is expected 100% of the time. Hand hygiene reports are regularly delivered to the hospital board and tied to financial incentives for hospital and medical staff. Hospital leaders take these basic measures seriously and counsel employees or physicians who repeatedly fail to comply even after reminders from other staff members. The Chief Medical Officer is a big supporter of infection prevention measures and I can count on him to counsel physicians who fail to comply with isolation measures. The first counseling is a reminder. The second counseling session is a serious discussion that clearly defines the expectations for compliance with hospital policy.

It is rewarding to work in a hospital that is committed to infection prevention. Hospital leaders provide the Infection Prevention Department with the resources we need including an adequate number of Infection Preventionalists, IS support, continuing education, and backing when we encounter difficult issues. We want our patients and the community to have confidence that they can expect excellent care when they come to Piedmont Hospital, and we voluntarily post many of our quality outcomes, including hospital acquired infection rates, on our public internet site. (A screen shot from our website is shown in Illustration1.) Our goal is to one day say, "You will not get an infection if you come to Piedmont Hospital."

Janet H. Keen, RN, MS, CIC, is director of infection prevention at Piedmont Hospital, Atlanta.