Reducing Clostridium difficile in the Rehabiltation Setting: A Team Approach for Better Results

Background: C. difficile is an enteric pathogen that has become more virulent with adult hospitalizations increasing from 5.5 cases/10,000 in 2000 to 11.2 in 2005 (23% annual increase). Infections can cause severe disease including toxic megacolon and death, with relapses common. C. difficile in the U.S. is associated with antibiotic use, hospital stay, and age (>65). Other risk factors include GI surgery, ICU stay, and invasive GI devices. The attributable inpatient cost of C. difficile disease in 2003 was estimated to be $1.3 billion.  

Bryn Mawr Rehabilitation Hospital receives high-risk patients from a variety of acute care facilities and nursing homes. Many patients have had lengthy, complex stays prior to their rehabilitation, including surgery, ICU stay, and antibiotic therapy. We began tracking C. difficile infection in 2006 and noted an increased infection rate in 2007. Our rooms are semiprivate and patients with C. difficile infection traditionally shared rooms with non-infected patients.  One of the measures implemented was providing a bedside commode for the patient while the well roommate used the bathroom, and vise versa. This led to staff confusion and inconsistency. Additionally, staff hand washing sinks are not conveniently located close to patient care areas. In response, a multidisciplinary team was formed.

Objective: The multidisciplinary team was tasked with examining the problem and designing interventions to reduce C. difficile infection.  Interventions had to be adapted to our rehabilitation environment. The objective was to reduce the infection rate to pre 2007 levels.

Methods: Measurement: Hospital associated C. difficile infection/patient days X1000. Definition: new onset C. difficile infection after day 3 of hospitalization. Current CDC definitions do not take into account transfers between acute care hospitals and rehabilitation facilities.

Interventions included new cleaning protocols using bleach and Chlorox wipes and assignment of cleaning responsibility. Disposable supplies were ordered for isolation carts and patient hand wipes delivered on meal trays, in the dining room, and at therapy gym entrances.  New policies were developed for room assignment, hand hygiene auditing, and enhanced Contact Precautions with an updated C. difficile Protocol. A daily isolation list was implemented.  Education was created for patients/family and a C. difficile self-leaning module developed for nursing, therapy and environmental services.

Results: Rates decreased after interventions from 1.24 in 2007 to .56 in 2008. This rate decrease has been sustained into 2009.

Conclusions: We have been successful at reducing C. difficile infection rates nearly three fold. We now include C. difficile education in our mandatory yearly Computer Based Training program.