Challenges of Auditing Infection Prevention Practices in a Statewide CDI Collaborative

Background: Compliance with infection control (IC) practices is one way to minimize cross-transmission of C. difficile infections (CDI).  A large Ohio collaboration was formed to collate cases and to do a performance improvement project (PIP) with a goal to monitor and improve compliance with hand hygiene (HH), contact isolation (CI), and environmental cleaning (EC), via direct observational audits, to potentially decrease CDI rates.

Objective: To develop a standardized electronic auditing tool to document, assess and report individual facility compliance with recommended CDI reduction practices.  To compare quantitative and qualitative facility audits to CDI rates to determine the effects of prevention practices on the PIP unit to the CDI rates.

Methods: Through monthly conference calls, participants edited and approved electronic audit forms for HH, CI and EC observations by group consensus with a qualitative goal of 90% compliance with all components.  The forms were designed to calculate the compliance rates when completed, for immediate feedback to their respective PIP units.  Quantitatively, HH audits (30 observations/month) tracked compliance of staff entering/exiting rooms and if coaching was provided.  CI audits (20 and 30/month for facilities, <100 or >101 beds, respectively) focused on appropriate isolation signs and use of gown and gloves.  EC audits, (20/month for daily or discharge cleaning), focused on cleaning of high-touch surfaces in the patient’s room/bathroom.  Individual facility audits were sent to a data repository for de-identification and then faxed/mailed to the research team.  Due to lost or illegible data, electronic submission was later mandated to allow for direct file import into the newly created database.

Results:  Among the 59 facilities participating, audits were performed monthly on about 87 PIP patient care units.  Many facilities had difficulty completing the minimum number of audits.  The mean completion rates for the recommended number of audits were HH: 42% (range 35-51%), CI: 18% (10-27%), and EC: 30% (21-36%).  The turnaround time for receipt of faxed audits to the research center was rarely monthly, delaying comparison feedback of CDI rates to their IC practices. Individual facility qualitative compliance showed performance below 90% for HH, CI and EC, at 84% (range 80-88%), 58% (48-67%), 77% (69-85%), respectively.  Several participants reported that their submitted data was incomplete, and improper completion of forms by the facilities impaired the capability to employ the Excel calculations.

Conclusions: Despite the collaborative participants coming to consensus on the minimal number of observations, audit data was mostly incomplete.  Reports back to the facilities were initially hampered due to mailing / faxing. The goal of electronic real time feedback of monthly audits was not met.  Alternative auditing mechanisms need to be developed.