Sonoma Valley Hospital’s novel approach to reducing C. diff infections

  HOSPITAL
Sonoma Valley Hospital

PROBLEM
C. diff rates unimproved despite use of current “best practices”

SOLUTION
Improving and complying with current best practices, using LightStrike Germ-Zapping Robots,
using probiotics during antibiotic therapy and reducing use of PPIs

VENDOR
Xenex

Clostridium difficile (C.diff) infection rates continue to rise in California and across the United States, including during a period of time at Sonoma Valley Hospital (SVH) where Kathy Mathews works as an Infection Preventionist. In 2014, SVH set out to discover if the nationally recognized best practices were adequate to tackle the problem.

What they discovered during their investigation — and how SVH is successfully attacking C.diff today — could serve as a lesson for other hospitals with similar goals.

Initial steps

Infection control has always been a priority for SVH. Prior to Mathews’ arrival, efforts included a telemedicine Infectious Disease program which resulted in:

• Improved infectious disease consultations & education
• Empiric antibiotic recommendations based on the hospital’s antibiogram and national guidelines
• Reduction in the use of antimicrobials
• Weekly ID consultation with the infection preventionist, microbiology and pharmacy departments
• Development, implementation and oversight of the Antimicrobial Stewardship Program (ASP)

The ASP committee identified an overuse of Fluoroquinolones and Piperacillin/Tazobactam resulting in a combined cost of more than $60,000 in 2008. By 2011, the hospital reduced Fluoro usage by 77 percent and Pip/Tazo by 72 percent. Despite a focus on using the right drugs for the right bugs, they did not see a significant decrease in the C. diff infection rates. They had reduced pharmacy costs and antimicrobial use yet the C. diff infection rates had not improved by 2013.

“If we’re reducing the amount of antimicrobials, why are we having an increase in C. diff infections?” asked Mathews. “So we made C. diff reduction a performance improvement project in 2014.”

A multi-disciplinary approach

SVH left no stone unturned. They audited handwashing practice and determined that compliance had fallen off. A new handwashing campaign, High Five for Hand Hygiene, recognized and rewarded healthcare workers for proper hand hygiene. Compliance improved dramatically in 2016.

They also reviewed the 2012 FDA notice that proton pump inhibitors (PPIs) may be associated with an increased risk of C. diff diarrhea. Now, physicians change the PPIs to H2 blockers or discontinue PPIs altogether when possible.

They notified Nutrition Services of the research showing that probiotics given with antibiotics can reduce the risk of C. diff infection by 64 percent. However, Mathews said, the ASP took for granted that the patients were eating the live-culture yogurt as expected. Now, the pharmacy gives the dietician a daily list of patients getting antibiotics to make sure those patients also get the probiotics or yogurt. The dieticians educate the patients about the importance of consuming probiotics while they were on antibiotics and nurses gave additional information upon discharge. Compliance with probiotics has steadily improved. In June 2014, only 4.7 percent of patients were taking live-culture yogurt or probiotics with their antibiotics. Two months into the project it was up to 62.2 percent. In February 2016, SVH saw 95 percent compliance and 90 percent in 2017.

Bundled actions yield infection reduction results

Equally important was a review of the hospital’s environmental service practices, especially in rooms where C.diff patients were treated. How were the rooms being cleaned? What chemicals were being used?

In August 2014, Mathews said some very generous local citizens donated a Xenex LightStrike pulsed xenon ultraviolet (UV) light robot to the hospital. The donors were interested in healthcare-related technology and excited about the impact that pulsed xenon UV room disinfection technology was having on hospital infection rates in other cities. When Mathews read the peer-reviewed literature on Xenex Germ-Zapping Robots that was given to her by SVH’s CEO, she was impressed with the reductions in C. diff and MRSA infection rates reported by other hospitals. The literature associates pulsed xenon UV light disinfection and reduced risk of infection by destroying the pathogens that cause infections. “When we saw that, the decision to use the robots was easy,” Mathews said.

It was fall 2014 when the Germ-Zapping Robot, nicknamed Lisa, arrived and SVH revised its cleaning practices to include pulsed xenon UV disinfection after the Environmental Services staff terminally cleans each isolation room. Lisa is also used daily in the operating rooms, the emergency room isolation areas, and in the skilled nursing facility, which is the only unit with semi-private rooms. “We’ve seen greater than a 50 percent reduction in C. diff infections during the last two years, after the introduction of the pulsed xenon UV light disinfection and the other measures,” Mathews said.

In 2013, the C. diff infection rate was 13.4 cases per 10,000 patient days (benchmark 7.4 per 10,000 patient days). By 2015 the C. diff rate dropped to 5.6. “I like that we approach infection prevention from a nutritional standpoint and a high-tech standpoint, in addition to the handwashing and isolation that all hospitals are doing.” Mathews said. “It feels great knowing that our tremendous efforts to reduce C. diff infections are working.

“Our success also gives us the opportunity to educate other hospitals about our program in hopes that they can achieve similar results,” she continued. “I would encourage other healthcare facilities to consider doing the same things and assess whether they see improvement too.”