Success Story: No 'Bed' Bugs

By Terrica Adams, MSN, RN; Caprice Brown, BSN, RN; Donna Elion, BSN, RN; Sandra Hugan, DNP, RN; Florence Jones, DNP, RN; and Lelia Winfield, BSN 

Clostridium difficile infection (C. difficile) is the most significant cause of hospital-acquired diarrhea. Data from the Center for Disease Control and prevention (CDC) reports, 14,000 Americans die every year from diarrhea causing C. difficile (2012). The organism is responsible for greater than 337,000 hospitalizations yearly and at least $1 billion in extra costs for healthcare. According to Burnett, et al. (2013), there have been significant epidemiology changes over the past decade related to C. difficile contamination.

C. difficile is a bacterium that forms spores. C. difficile may be transferred to patients via the hands of health care personnel who had contact with contaminated patients or their feces or contact with contaminated equipment. In a C. difficile infection, spores are ingested via the oral route. Patients who are undergoing antimicrobial treatment are at a higher risk of getting C. difficile because it proliferates under the con-dition of altered intestinal flora. The spores then produce toxins that damage the intestinal lining, which causes it to shed in the form of diarrhea. One unintended consequence of frequent diarrhea is electrolyte imbalance, specifically hypokalemia, which can cause significant disturb-ances in heart rhythm.

A large -scale evolution occurred and C. difficile has become the most common healthcare-associated infection in hospitals and community settings. Aroori, et al. (2009) indicate there are several reasons for the increasing incidence of C. difficile infection. These reasons include, but are not limited to, lack of awareness and adequate knowledge among healthcare professionals, increasing elderly population, overcrowding of hospitals, poor compliance with hand hygiene and environmental cleaning standards. The one key strategy to prevent hospital-acquired infections, such as C. difficile, is good hand hygiene. Hospitals have implemented special cleaning practices for rooms that have housed patients with C. difficile. Patients who are diagnosed with C. difficile are also placed in isolation to prevent the spread of the bacteria. High levels of awareness among hospital staff can reduce the number of infected cases and C. difficile infection associated morbidity and mortality (Aroori, et al. 2009). In this article, we will describe the actions that were taken to decrease the C. difficile rate in our hospital.

The Innovation and Research Shared Governance Council held its first meeting in February 2012. The council was created to demystify research for the bed side nurse, provide a forum to review evidence- based literature, and demonstrate how it applied to daily practice.  Basically, the council wanted to serve as a link exposing nurses to evidence-based practice and research. Members of the council selected articles from peer-reviewed journals and created posters on the article. 

One of the first articles selected by the council was on C. difficile infection. The local newspaper, The Commercial Appeal in Memphis, Tenn., featured an article titled, “Rise in C. difficile Infections Concerning” (2011).  A nurse who works in the gastroentrology lab shared the article with the council members who were very interested in the topic. Reduction in C. difficile rate was a key quality measure on the hospital’s bal-ance score card and now a hot topic in the community.   
At the next meeting, council members reviewed hospital C. difficile data and other evidence-based articles on C. difficile. An article titled “The Role of Environment Cleaning in Health Care-Associated Infections” (2011) was selected for the poster presentation. Significant discussion occurred between council members regarding the mode of C. difficile transmission. Some of the council members shared stories of patients being transported on obviously soiled stretchers, beds, and other equipment. The Innovation and Research Council decided to educate hospital staff on C. difficile through a poster presentation and the monitoring of equipment for cleanliness following the education.

The C. difficile poster focused on the following items:  1) what is C. difficile 2) symptoms 3) causes 4) prevention 5) treatment 6) risk factors and 7) complications. The poster traveled to the environmental services department, guest services (transporters) department and each nursing unit. Department directors were encouraged to discuss the poster in huddles and meetings. The posters were placed in the breakroom for staff to read while on breaks. Staff members who reviewed the poster were asked to sign an in-service roster and received credit for education activity. Each area was given 14 days to review the poster. Circulation of the poster took three months to complete.   

While the poster was circulating on the units the council developed a survey tool to audit the cleanliness of equipment used for patient care. The audit addressed the following questions:
- Which department did the patient come from?
- What is the admission date?
- Are there dirty articles (i.e., bed pan, urinal, clothing, tape residue, etc.) on the bed?
- Does the bed have any visible soils? If yes, does the soil appear to be body fluids?
- Is the patient’s body dirty or do they have a body odor?

The nurses in the gastroenterology lab, same-day surgery, and the post anesthesia care unit agreed to complete the audits. These nurses monitored equipment for contamination and visible soils for one month, Aug. 22, 2013 to Sept. 24, 2013. Patients were transported on equip-ment from the following units: same day surgery, medical/surgical units, emergency department, and intensive care unit. A total of 101 audits were completed on equipment from these units. The results were:
- Dirty articles: 8 beds had dirty articles on the bed
- Visible soils: 13 beds have visible soil on the bed (tape residue or dirty)
- Body fluids: 11 beds had dried body fluid
- Body odor/not clean: 5 patients were not clean
- No finding: 64 beds, stretcher or patients had no findings

The Innovation and Research Council shared the results with nursing leadership. The chief nursing officer (CNO) instructed the directors to share the results with their staff during staff meetings and huddles. Each nursing unit was asked to complete action plans to address issues spe-cific to their unit. The CNO asked the council to repeat the survey in four months.

A total 121 audits were completed on second assessment. There was improvement in all areas accept one. The results were:
- Dirty articles: 0 dirty articles on the bed
- Visible soils: 2 beds have visible soil on the bed (tape residue only)
- Body fluids: 37 beds had dried body fluid (27 of the beds came from one unit. Also this unit experiences an increased use in agency nurses)
- Body odor/not clean: 1 patient smelled of urine
- No finding: 81 beds, stretcher or patients had no findings

During the same time the Innovation and Research Council focused on C. difficile, the quality department in the hospital monitored C. difficile cases and shared results with the units, tracked and trended the C. difficile rate for each unit.  Staff was educated on Centers for Disease Control and Prevention (CDC) guidelines for C. difficile.  The C. difficile rate for the facility went from 4.60 in 2012 to 3.69 in 2013. Increased awareness and focus lead to improvements.  The Innovation and Research Council achieved the goal of demystifying research and demonstrated how evidence-based literature can be applied to daily practice.

Four key lessons learned include:
- When sharing evidence-based literature highlight key elements and keep the presentation simple (i.e., poster presentation) to encourage staff to read the content.
- Some staff will want more detail.  Have available articles and websites that Council have reviewed and can recommend.
- Keep the topic alive.  The poster presentation traveled for three months and follow-up audits with unit-specific feedback on results and ac-tion plans for improvement occurred over six months.
- Involve everyone! Nursing leaders, quality leaders, frontline staff on nursing units, transporters and environmental services employees.

Members of the Innovation and Research Council Shared Governance Council were highly engaged in the project and extremely pleased with the results.  The council challenged other shared governance councils to embrace research and show how the findings can be applied to the daily practice of the bedside nurse. The application can lead to improved patient outcomes.

Caprice S. Brown, BSN, RN is currently a transitional care nurse for Methodist University Hospital, Memphis, Tenn.

Donna D. Elion, BSN, RN is currently a staff nurse in the GI/OR Department and PICC nurse at Methodist South Hospital, Memphis, Tenn.

Florence Jones, DNP, RN, NEA-BC, FACHE is currently the CNO at Methodist North Hospital, Memphis Tenn.

Lelia Winfield, BSN, RN is currently a nurse in Same Day Surgery/PACU at Methodist South Hospital in Memphis, Tenn. She was recently chosen as Methodist South's Nurse of the Year 2014.

Sandra Hugan, DNP, MBA, RN is currently the director of emergency services at Methodist South Hospital, Memphis Tenn.

References
Aroori S, Blencowe N, Pye G and West R. (2009). Clostridium difficle: How much do hospital staff knows about it? Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966196/
 
Burnett E,  Kearney N, Johnston B, Corlett J and  MacGillivray S. Understanding factors that impact on health care professionals’ risk percep-tions and responses towards Clostridium difficile and methicillin–resistant Staphylococcus aureus. Am J Infect Control. 41(5):394-400. 2013.

Centers for Disease Control and Prevention. (2012). CDC warns the public about deadly C. diff infections, patient safety advocates react. Re-trieved from: http://safepatientproject.org/posts/3009-cdc-warns-the-public-about-deadly-c-diff-infections-patient-safety-advocates-react

Jain M. Rise in C. difficile infections concerning. The Commercial Appeal. March 28, 2011.   Retrieved from http://www.commercialappeal.com/news/2011/mar/28/rise-in-c-difficle-infections-concerning/

Kleypas Y, McCubbin D and Curnow E. The role of environmental cleaning in health care-associated infections. Critical Care Nurse Quarterly 34 (1): 7-11. 2011.