The Importance of Hand Hygiene in Clostridioides difficile Reduction

Male health care worker wash his hands

(Adobe Stock 394959548 by Roman)

Preventable health care-associated infections (HAIs) are a significant issue in the US health care system, impacting patient health, increasing hospital costs, and leading to revenue losses. One common type of HAI is Clostridioides difficile, which had 43,387 hospital-acquired cases reported between April 2021 and March 2022 by the Centers for Medicare & Medicaid Services (CMS) Quality Metrics data.¹ C difficile leads to rehospitalization, complications, longer hospital stays, and even death, costing the US health care system about $5 billion each year. Recurrent cases alone cost $2.8 billion.² The average cost of 1 C difficile case is approximately $17,260.3 Additionally, there is a concerning excess mortality rate of 44 deaths per 1,000 in hospital C difficile cases, underscoring the need for effective prevention strategies.³

C difficile is more common than other HAIs because its spores are difficult to eliminate. The American Journal of Gastroenterology emphasizes hand hygiene as the cornerstone of C difficile prevention.⁴ However, alcohol-based hand antiseptics are not effective against C difficile spores, thus washing with soap and water is recommended to reduce spread.⁴ In addition to hand hygiene, the Society for Healthcare Epidemiology of America suggests isolating C difficile-infected patients.⁵

By implementing prevention strategies, health care facilities can work towards reducing C difficile prevalence and associated costs, improving patient outcomes, and reducing the burden on the health care system. In this research study, we observe the effect of 10 short-term acute care hospitals and their implementation of an electronic hand hygiene monitoring system (EHMM) as their prevention strategy. The EHHMS served to both isolate patient care requirements, in addition to specific hand-washing reminders to staff.

Electronic Hand Hygiene Monitoring

There are currently various EHHMS companies, all with unique designs and features. The system in this research offers a design consisting of 4 main hardware components. First, a wearable device provides real-time hand hygiene reminders to the users, sink sensors, room beacons, and stations that charge the wearable badges and facilitate data transmission from each badge to a client-specific dashboard.

When combating C difficile, the room beacons play a crucial role. These beacons can designate a room as a Contact Plus location, allowing the specific room beacons to enable the badges worn by staff to generate specific reminders for hand washing instead of hand sanitation. This targeted approach ensures that staff members are reminded to practice proper hand hygiene when treating and exiting a room where a patient is treated for a Contact Plus pathogen like C difficile.

Short-Term Acute Care Hospitals

In the US, different types of hospitals exist, with short-term acute care hospitals being the most prevalent, accounting for more than half of all hospitals. This research focuses on these hospitals because they provide a wealth of publicly accessible performance data on the CMS website.¹ To be included in the C difficile study, hospitals had to meet specific criteria:

1. They must be short-term acute care hospitals.
2. They must be clients of EHHMS Company, with full installation and usage starting between 2016 and 2021.
3. They should have at least 1 year of CMS HAI data before using EHHMS and at least 2 years after implementation.
4. There should be no missing C difficile data during the study period.
5. CMS HAI data must be reported for individual facilities rather than for health systems or multiple locations.

Based on these criteria, EHHM identified 10 hospitals from various regions, including the Western Mountain, Western Pacific, Mid-Atlantic, and Northeast. The bed counts of these hospitals range from just under 100 to just under 500, with an average of 239 beds across all facilities.

Methods

Data for this research was obtained through 2 sources. The first was publicly available HAI data through the CMS Provider Data Website over the 2015 to 2021 calendar years.¹ The second was hand hygiene data recorded by the EHHMS client-specific dashboard. In this analysis, we looked at the following data groups: Number of health care-associated C difficile by year, total number of hand-hygiene opportunities (HHOs), and overall facility-wide adherence.

Statistical Analysis

For C difficile observed counts by year, we performed additional calculations to compare counts over time. We first took the HAI count for the year before EHHMS Installation (Control Year). Next, we computed the average counts for each year from the EHHMS full-site usage up through the end of 2022 (study years) for at least 2 years. Then, we compared both averages against one another and calculated the percentage change of the study years from the control years, as in the equation below:

Results

From the contract beginning to the present date, the EHHMS has recorded approximately 145 million total hand hygiene events for all 10 facilities. The average all-time compliance rates for each facility fell in the range of 90% to 96%, with a combined overall mean hand hygiene adherence of just over 93%. The earliest contract began in 2016, with the most recent in 2021.

Based on our research of hospital use of EHHMS, we observed a significant impact on the number of health care-associated C difficile cases at all 10 facilities from 2015 through 2022. After the first year of EHHMS implementation, there was a noticeable decrease or stabilization in the reported C difficile HAIs. Furthermore, 8 out of the 10 facilities performed below their nationally predicted benchmark, indicating a positive outcome compared to previous years where counts were at or above the benchmark.

Our analysis calculated the average decrease in nosocomial C difficile by comparing the average health care-associated C difficile count of all years before EHHMS adoption with the case counts in all eligible years up to 2022 post-adoption. Hospital 8 showed the largest average observed reduction at 82.35%, while Hospital 9 had the smallest average reduction at 25.00%. On average, there was a mean reduction of 53.15% across all facilities.

Footnote. This graph shows each of the 10 hospitals in this study with CMS C difficile HAI data per year from 2015-2022. Observed C difficile counts are noted from CMS provider data releases. The red arrow present for each facility signifies the year of EHHMS adoption.

(Credit: author)

Discussion

The outcomes of this study do suggest a correlation between the use of EHHMS as a prevention and control measure and a reduction in observed counts of health care-associated C difficile cases across multiple short-term hospital facilities. This research, however, is just a starting point and needs to be continued for these same facilities and repeated for additional locations of similar and different facility types in the coming years. This research should also be expanded to better understand the effect on hospital performance that comes from reduced C difficile cases, including the minimized patient days with decreased lengths of stay, reduced mortalities, and cost savings.

The limitations of this study should also be taken into consideration. Firstly, the variability in the pilot periods for EHHMS implementation across different facilities—differing in duration, number of units, and types of units—may have influenced the average counts for the years leading up to implementation, as the analysis begins only after this pilot phase. Secondly, the inconsistency in the use of Contact Plus room assignment during 2020 and 2021, particularly due to interruptions caused by the SARS-CoV-2 pandemic, could have affected the results observed by post-installation. Lastly, while the study primarily examined the impact of EHHMS, it is important to recognize that facilities may have implemented other strategies to reduce health care-associated C difficile cases, such as changes in environmental disinfection practices. However, no such strategies were reported to the research team.

Conclusion

Proper hand hygiene is important in addressing C difficile, which is the most prevalent and deadly among HAIs impacting our nation’s health system today. This research indicates that partnering with an EHHMS has successfully reduced health care-associated C difficile case counts. It emphasizes the necessity for ongoing research into the use of EHHMS for C difficile reduction to validate these findings and to support the continued progress in reducing C difficile rates in short-term acute care hospitals throughout the US.

References

1. U.S Centers for Medicare & Medicaid Services. Hospitals Data Archive. Accessed November 15, 2024. https://data.cms.gov/provider-data/archived-data/hospitals
2. Feuerstadt P, Theriault N, Tillotson G. The burden of C. difficile in the United States: A multifactorial challenge. BMC Infect Dis. 2023;23(1):80. doi:10.1186/s12879-023-08096-0
3. Agency for Healthcare Research and Quality. Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital-Acquired Conditions. Published 2017. Accessed November 15, 2024. https://www.ahrq.gov/hai/pfp/haccost2017-results.html
4. Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478-498. doi:10.1038/ajg.2013.4
5. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-455. doi:10.1086/651706