Preventing the Spread of Clostridium Difficile - Essay Example

Preventing the Spread of Clostridium difficile through Systematic Change in Hand Hygiene at the Point of Care By Table of Contents I. Chapter One: Introduction and Overview of the Problem of Interest A. Background B. Significance C. Question Guiding Inquiry (PICO) D. Conclusion II. Chapter Two: Review of the Literature/Evidence A. Methodology (for the search & review process) B. Findings (integrative review of the literature) C. Limitations (of the search & review) D. Conclusions (based on the evidence) III. Chapter Three: Conceptual Model A. Introduction B. Theorist C. Model D. Conclusion IV. Chapter Four: Project Design A. Introduction B. Project Description and Planning C. Conclusion V References Introduction and Overview of the Problem: Increased rates of Morbidity capitalization and mortality among hospitalized patients are being directly related to healthcare-associated (nosocomial) infections worldwide. Clostridium difficile associated disease (CDAD) is a major source of healthcare associated infection. Epidemiologic studies continue to demonstrate that simple hand hygiene produces positive effects in the prevention of HAI (nosocomial) pathogens throughout health care facilities. Health care workers (HCWs) are often reminded of the importance of hand hygiene in the prevention of health-care associated infections.  Background (problem and supporting information) Clostridium difficile (C. diff)word missing here a gram-positive anaerobic bacillus closely related to the microbes causing tetanus and brutalism .It is associated with gastrointestinal infection, diarrhea and pseudo membranous colitis. C.diff generally afflicts older hospitalized patients treated with antibiotic drugs. It has two forms: an active form that is virulent and infectious, and inactive form, which is called a spore, is not infectious. Spores can change into the active, infectious form inside the host body. Active forms do not survive for a longer period in the environment contrary to the inactive spores, which can survive in the environment for a prolonged period. C.diff accounts for 20% -30% of cases of antibiotic-associated diarrhea and is the most commonly recognized cause of infectious diarrhea in healthcare facilities (Bartlett 2002). Annually the excess hospital costs due to its infection in the US are estimated to be $3.2 billion for the years 2000–2002 (O’Brien et al. 2007). Between 2002 and 2006 hospital outbreaks were severe (Loo et al. 2005) and recurrent (Pepin et al. 2005).More than 28,000 deaths occur every year in US (Weis, 2010) with overall mortality of 10-15%. Its infection has been on missing word rise in the US and elsewhere. The recent emergence and spread of virulent strain of C.diff which is commonly known as NAP1/B1/027 produces more potent toxin and was first identified in Quebec, Canada in late 2002. It has since been found in most states in the U.S. Realizing the severity and threat to patients, hospitals and other healthcare facilities the control and prevention of the disease is really challenging, steps have been taken to stop the spread of C.diff, but more needs to be done.  Clostridium difficile associated disease (CDAD) is a major cause of healthcare associated infection causing morbidity and mortality. The spores are found in hospitals, and medical care facilities, located on the floors, furniture, linens, toilet seats, telephones, shared instrumentation and healthcare workers hands and accessories. According to McFarland et al. (1989) environment samples showed 29% positive for C.diff from rooms occupied by asymptomatic patients and 49% in rooms having patients with CDAD. Fawley and Wilcox (2001) showed significant incidence of C.diff due to environmental factors.  Recently C.diff has become more toxic and acquired more resistance to drugs besides it is no longer restricted to patients in hospitals or nursing homes as sizable infections are reported from outside of these facilities. The efficacy of antiseptic hand wash or hand-rub preparations against C.diff has become a great concern as none of the agents (including alcohols, chlorhexidine, PCMX, and triclosan) is effective against virulent strain. Washing hands with soap and water may help to physically remove spores from the surface, however, rigorous regimen of hand hygiene is required. Hand washing (soap washing and water), contact precaution, and meticulous environmental cleaning with an EPA-registered disinfectant are effective in preventing the spread of the organism (McFarland et al. 1989). In places with high endemic C.diff infection rates or in an outbreak setting, the use of dilute solutions of 5.25-6.15% sodium hypochlorite for routine disinfection (Category II) is recommended. Glutraldehyde, OPA and peracetic acid have been shown to be effective in killing spores. The strategic goals that are generally agreed by the experts of prevention and control of all infectious diseases are: to detect, report, and prevent transmission of infectious organisms, and the interventions that include aggressive detection, isolation of patients, appropriate hand hygiene, thorough disinfection of the environment and personal equipment. Even though, every aspect of the mentioned intervention may seem self-evident, the key to preventing transmission is practice of all components (all components of what? There seems to be a word missing) along with the judicious prescription of antibiotics to mitigate the spread of infection. Better compliance and audit to redesign (the phrase audit to redesign does not make sense to me) the process is showing results in controlling the disease, albeit, significant data sources showing radical change are not globally available. It is prudent to suggest that hand hygiene (seems like something is missing here, but I am not sure what) exceeds current practices in most health care settings with judicious prescription of antibiotics to ward of any endemic (do you mean epidemic?). The drugs of choice are frequently the same drugs that cause C.diff (do you really want to use the abbreviation? I think the entire thing should be in italics): metronidazole and vancomycin. Significance of the problem (Why this problem needs to be addressed) C. diff produces toxins which can cause dehydration related to diarrhea, toxic megacolon, colitis, sepsis, and death. Clostridia (I think Clostridia should be in italics) are spore-forming bacteria; diarrheal patients in hospitals or other settings shed thousands of their spores with each bowel movement. Much like the Tuberculosis Spore, C.diff spores are resistant to most germicidal agents and can persist in hospitals, nursing home wards, and inanimate objects for long periods of time. As a result of C.diff spores longevity, C.diff infection is becoming more prevalent outside of the hospital setting (community-acquired). Most importantly, C.diff infections are occurring in the absence of prior antibiotic exposure. Current evaluation of best-practice in the prevention and treatment of C.diff has revealed the vast majority of severe morbidity and mortality from C. diff exposure is experienced in the elderly population. Further studies conducted by the Center for Disease Control revealed that for almost three decades, physicians have recognized C.diff infection as the main cause of bacterial diarrhea during or following antibiotic treatment of other infections. Louie (2007) documented that in recent outbreaks of C. diff infections are continually being reported in many countries around the world. In the past, C.diff had been associated with antibiotic use; however C.diff related nosocomial infections and community acquired C.diff infections are rising at an alarming rate. Centers for Disease Control and Prevention (CDC) is calling for more stringent prescriptive guidelines to limit unnecessary and inappropriate use of antibiotic therapy, along with other preventive measures such as placing patients with known or suspected C.diff under isolation precautions and educating hospital staff on hand hygiene. The spread of C. diff within institutional settings is dependent on staff compliance with national guidelines and standards hygiene protocols such as the WHO hand hygiene recommendations listed under "My 5 moments for Hand Hygiene". Unfortunately, a recent study revealed that protocols for targeted hospital acquired infections are not always congruent and is dependent on the how well staff have been educated on the fact that C. diff produces spores that can withstand hostile environments and are resistant to alcohol hand rubs and other routine antiseptics. Therefore, the best way to remove spores is by diligent hand washing. Preventing the spread of C. difficile within institutional settings is dependent on staff compliance with national guidelines and standards as put forth by locally determined hygiene protocols. Over the past several years there has been a significant increase in the incidence of preventable Health Care Infections such as Clostridium Difficile. The World Alliance for Patient Safety launched by The (here you used a capital T) WHO in 2004 advocates a, “clean care is safer care,” program, in which health care leaders sign a pledge to take specific steps to reduce hospital associated infections in their facilities. Hand hygiene is the first focus in this worldwide initiative. Recognizing a worldwide need to improve hand hygiene in healthcare facilities, the (here you used a lower case T)WHO produced Advance Draft, launched its “Guidelines on Hand Hygiene in Health Care” along with the “Implementation Toolkit” that have been available since May 5, 2009, on the occasion of the launch of the “Save Lives: Clean Your Hands” initiative. The WHO regards hand hygiene as an essential tool for the prevention of nosocomial infection, but compliance in clinical practice is often low.  Clostridium Difficile infections Alcohol Hand Rubs verses Hand washing with soap and water (Clostridium Difficile requires soap and water).is this a topic? I have a question about this as well Question Guiding Inquiry (PICO) Formulating a clinical question in such a manner that allows the most relevant and best- evidence to be synthesized into a valid clinical question is the first step of evidence-based practice (Melynyk & Fineout-Overholt, 2005). When looking for an answer to clinical questions, the PICO model is the most effective way a search can be performed. That is where PICO, a model used to formulate clinical and of four key elements incomplete sentence: P = Patient or population; I = Intervention; C = Comparison; and O = Outcome. Writing out a question allows the clinician a way to clarify exactly what is needed to provide the answer. Clinical question: Will Training and Education utilizing the WHO recommendations for improvement of hand hygiene and VHAs Hand Hygiene Directive 2011-007 improve hand hygiene practices of health care workers, thereby preventing the spread of Health Care Infections (HAI). Population: RNs, LPN/LVNs and Nursing Assistants who provide direct patient care on nursing units: 5A, 5C, 4A, 4C and Community Living Center-B (CLC-B) Intervention: Training and Education utilizing the WHO recommendations for improvement of hand hygiene and VHAs February 16, 2011 Hand Hygiene Directive. Comparison (C): A comparison of pre and post-tests will be conducted to determine the participant’s understanding of VHAs Hand Hygiene Directive and the WHO model and the impact of hand-washing technique on the incidence of C. diff. Outcome: Improved knowledge of how hand hygiene practices/compliance will prevent the spread of HAIs, especially. Conclusion C.diff infections are on the rise around the world; going from being associated with antibiotic therapy, to a nosocomial infection and finally, moving from within the hospital setting and into the community. At this time, the majority of patients affected are the older adult population, however it is clearly a matter of time before C. diff becomes prevalent among all age groups. Hand Hygiene is imperative to breaking this chain of events. Literature Review Increased rates of Morbidity and mortality among hospitalized patients are being directly related to healthcare-associated (nosocomial) infections worldwide. Clostridium difficile associated disease (CDAD) is a major source of healthcare associated infection. Epidemiologic studies continue to demonstrate that simple hand hygiene produces positive effects in the prevention of HAI (nosocomial) pathogens throughout health care facilities. Health care workers (HCWs) are often reminded of the importance of hand hygiene in the prevention of health-care associated infections. However, compliance among healthcare workers in regards to the recommended hand hygiene procedures, remains at an all-time low. WHO (2009), during the launch of "Save Lives: Clean Your Hands" Initiative, recognized a need for international development of hand hygiene implementation programs within healthcare facilities. With this recognition, WHO (2009) produced “The Advance Draft’’ launched its “Guidelines on Hand Hygiene in Health Care” along with the “Implementation Toolkit”, With production of the Advanced Draft, the strategy for implementation was also developed along with a wide range of tools to help healthcare settings translate the guidelines into practice. A key feature of the implementation strategy is “My five moments for hand hygiene” integrates the indications and sequence for hand hygiene and facilitates appropriate training in implementation of these five key moments of healthcare delivery (Sax, Allegranzi, Uckay, Larson, Boyce, and Pittet, 2007). Background According Collis (n.d), the World Alliance for Patient Safety launched by The WHO in 2004 advocates a “clean care is safer care” program, in which health care leaders sign a pledge to take specific steps to reduce hospital associated infections in their facilities. The first focus of this worldwide initiative is hand hygiene education and training among healthcare workers, particularly those who provide direct patient care. Hospital Acquired Infections (Nosocomial), especially C. diff are increasing in number, morbidity, and mortality. Nosocomial infections are preventable through proper hand hygiene. Significance of the problem/purpose of the literature review is being led by the question; Will systematically changing health care workers (RN’s, LPN’s and NA’s) hand hygiene behavior of at the point of care, prevent the spread of C. diff. ? Method: An extensive review of the literature was performed utilizing resources from; VAMC and Chatham University libraries, as well as data bases to include, Nursing Center, CINHAL, Pub-Med, Med-Line, OVID and Meta-analysis sources from WHO, CDC’s, SHEA and IDSA. A review of the literature was guided by key words obtained from the PICO question pertaining to changing hand hygiene at the point of care. Selected studies included the key words: Clostridium difficile (C.diff), hand hygiene compliance, nosocomial infection, hand hygiene behavior, health care associated infections (HAI). There are many published research journal articles to include primary (Level 1) and secondary (Level 2) sources emphasizing the importance of hand hygiene in preventing nosocomial infections (frequently referred to Hospital Acquired Infection (HAI)), such as C.diff. Due to the enormous quantity of reviews on hand hygiene in the prevention of HAIs, it became necessary to limit the amount of selected studies to those specifically examining the use of educating HCWs on proper hand hygiene protocols, as interventional tool in preventing the spread of HAIs, especially C.diff. The literature search was further limited to research utilizing randomized control studies which are considered to be the "Gold Standard" for research studies. Finding Analysis conducted, based on the data available through the aforementioned areas, postulate that randomized control trials conducted for the use of consistent hand hygiene protocols will prevent HAI’s. However, the critical analysis highlights that poor compliance or non-compliance could possibility be related to a lack of knowledge on how HAI’s (especially C.diff) are spread. Therefore, the PICO question for this practice change project specifically targets HCWs (RNs, LPNs and Nursing Assistants who provide direct patient care. The need for providing healthcare workers with rigorous educational and training programs, then incorporate feedback regarding their performance, are considered integral parts of a successful hand hygiene campaign (Boyce and John, 2008). There is no shortage of relevant documentation or guidelines on hand hygiene, and there is no hesitation to recognize the exemplary job of the WHO, CDC, SHEA, Joint Commission and IDSA for their role in the field of prevention and control of HAI’s (especially C.diff). The question of hand hygiene in the prevention of HAI’s is becoming an international endeavor. Therefore, further research is needed to develop reliable and reproducible methods for monitoring hand hygiene compliance. Limitations: No limitations in the quantity or quality of available literature is noted. In-fact, CDC and WHO have launched hand hygiene campaigns causing a surge in research. This surge has produced a significant number of Type I Meta-Analysis Reviews. Discussion The efficacy of antiseptic hand wash or hand-rub preparations against HAI’s, especially C. diff, is a great concern, as none of the agents (including alcohols, chlorhexidine, PCMX, and triclosan) have been proven effective against virulent spore forming strains. Washing hands with soap and water may help to physically remove spores from the surface; however, rigorous regimen of hand hygiene is required. Hand washing (soap washing and water), contact precaution and meticulous environmental cleaning with an EPA-registered disinfectant are effective in preventing the spread of the organism (McFarland, Mulligan, Kwok and Stamm 1989). According to Haas and Larson (2008) hospitals can improve compliance of hand hygiene by assessing the barriers to it, measuring the rates of compliance, education staff on the importance of hand hygiene, making sanitizing products more accessible for staff use, and holding employees accountable. They believe that lasting improvement in hand hygiene is a collaborative effort that depends on the committed support of hospital administrators. Conclusion The strategic goals that are generally agreed by the experts of prevention and control of all infectious diseases are: to detect, report, and prevent transmission of infectious organisms, and the interventions that include dynamic awareness, isolation of patients, proper hand hygiene, thorough disinfection of the environment and personal equipment. Even though, every aspect of the mentioned intervention may seem self-evident, the key to preventing transmission is application of all components. Better compliance and evaluation to redesign the system is showing results in controlling the disease, albeit, significant data are not available globally of structural change. It is advisable to suggest that hand hygiene exceeds current practice in most health care settings. Reference Bartlett JG (2002). Clinical practice. Antibiotic-associated diarrhea. N Engl JMed; 346:334–49. Boyce, John M (2008). Hand hygiene compliance monitoring: current perspectives from the USA. Journal of Hospital Infection 70(S1) 2-7. Retrieved from nkinghub.elsevier.com/retrieve/pii/S0195670108600031 Boyce JM, Pittet D (2002). Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection CDC Newsroom (2008). Have you heard archive. 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Detecting hidden environmental reservoirs of Clostridium difficile during an outbreak associated with North American pulsed-field gel electrophoresis type 1 strains. Am J Infect Control 37:15-9. Retrieved from ww.ajicjournal.org/article/S0196 6553(08)00750-5/abstract Gerding DN, Johnson S, Peterson LR, et al. (1995). Clostridium difficile–associated diarrhea and colitis. Infect Control Hosp Epidemiol; 16:459–477. Retrieved from www.ncbi.nlm.nih.gov/pubmed/7594392  Haas J P, Larson, E L (2008). Compliance with Hand Hygiene Guidelines: Where are we in 2008?  American Journal of Nursing.  108(8): 40-44. Retrieved from www.nursingcenter.com/prodev/ce_article.asp?tid=807077 Institute for Healthcare Improvement (2006). How-to guide: Improving hand hygiene. A guide for improving practices among health care workers. Cambridge, MA; Retrieved from www.ihi.org › Home › Topics › Critical Care › Intensive Care –  Joint Commission (2005). An evidence-based method for improving staff hand hygiene.  Joint Commission Benchmark 7(3): 8-11. Retrieved from www.nursingcenter.com/prodev/ce_article.asp?tid=807077  Joint Commission (2007). National Patient Safety Goals. Retrieved from www.National Patient Safety Goals -- Joint Commission -Florida Hospital. Khoury, Rita H., Ryzhkova, Irna Y., Gudaitis, Peter, Gandhi, Asha, Salmon, Bernard, Gudaitis, Duana, Gudaitis, A.V. (2007). Clostridium difficile in geriatric population. Retrieved From www.aculabs.com/publications/Cdiff.pdf Larson EL, Early E, Cloonan P, et al. (2000). An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med. Spring;26:14–22 Loo VG, Poirier L, Miller MA, et al. (2005) A predominantly clonal multi-institutional outbreak of Clostridium difficile–associated diarrhea with high morbidity and mortality. N Engl J Med; 353:2442–2449. McFarland LV, Mulligan ME, Kwok RYY, Stamm WE (1989). Nosocomial acquisition of Clostridium difficile infection. N Engl J Med; 320:204–10. Melnyk, B.M. & Fineout-Overholt, E. (2005). Evidence-based practice in    nursing & healthcare: A guide to best practice.  Philadelphia. Lippincott Williams & Wilkins. O’Brien JA, Lahue BJ, Caro JJ, et al. (2007). The emerging infectious challenge of Clostridium difficile–associated disease in Massachusetts hospitals: clinical and economic consequences. Infect Control Hosp Epidemiol; 28: 1219–1227. Pepin J, Alary ME, Valiquette L, et al. (2005). Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis; 40:1591–1597. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet (2007). ‘My fivemoments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect; 67: 9–21. Vicca AF (1999).Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit. J Hosp Infect.  Oct; 43(2):109–13.  Weise Elizabet (2010). Lesser known C.dificile a bigger threat than MRSA, USA Today. Accessed 03 March 2011. WHO (2009). WHO guidelines on hand hygiene in health care. First global patient safety Challenge-clean care is safer care. Retrieved from www.ncbi.nlm.nih.gov/pubmed/19508124 Please use these extra references to enhance this paper further: Hand Hygiene:: New Initiatives on the Domestic and Global Fronts, http://www.infectioncontroltoday.com/articles/2006/06/hand-hygiene.aspx Chapter 41. Preventing Health-Care Associated Infections (n.d). Retrieved from http://www.ahrq.gov/qual/nurseshdbk/docs/collinsA_PHCAI.pdf Compliance with Hand Hygiene Guidelines. (n.d) Retrieved from http://www.nursingcenter.com/prodev/ce_article.asp?tid=807077 Touch-Free Technology Combats Germs in the Hospital Washroom. (n.d) Retrieved from http://www.infectioncontroltoday.com/articles/2007/09/touchfree-technology- combats-grms-in-the-hospit.aspx Read More