Evidence-Based Intervention Reduces C. diff Rates in Adults With Cancer

Clostridium difficile (C. diff) is one of the most problematic health care-associated infections that practitioners continue to face in health care facilities; it is also the leading cause of hospital-acquired diarrhea in cancer patients who are undergoing chemotherapy. In fact, a recent study found that when compared with all patients in the United States, C. diff rates are twice as high in the oncology population; this is due to treatment or disease-related immunosuppression and neutropenia. For neutropenic patients, C. diff is a life-threatening complication that can potentially result in septic shock or death.

The University of California, Los Angeles, Santa Monica Medical Center (SMUCLA)’s inpatient, 26-bed medical oncology unit was struggling with an alarming rate of CDIs. To address the need for environmental disinfection of patient care areas, the unit practice council (UPC) called for the adaption of high-touch wipe down (HTWD), an evidence-based intervention. Due to the sustained success of the intervention in a vulnerable oncology population, HTWD has since been implemented hospital-wide.

C. diff is typically screened for upon admission and once a shift within the UCLA health system. A positive screen is indicated by 3 or more loose stools in a 24-hour period. The nursing bun­dle is then activated, which prompts staff to place the patient on contact-spore isolation, send a stool sample to rule out C. diff, maintain proper hand hygiene, wear personal protective equip­ment (PPE), and notify the physician. Despite consistent adherence to the organizational policy for early identification of C. diff, CDIs in the oncology unit were above the national median. To address the issue, the medical center sought to cut these rates in half from 2014 to October 2015.

The Centers for Disease Control and Prevention recommends the routine cleaning of environmental surfaces with C. diff sporicidal Environmental Protection Agency—registered disinfec­tant. High-touch surfaces, or those with frequent hand contact, should be cleaned more often than regular housekeeping areas. One report revealed a 40.5% decrease in CDIs on a geriatric unit when it was disinfected with bleach versus a neutral detergent. A later comparison of 2 intensive care units led to fewer CDIs in both units when adjunct bleach cleaning was performed in all patient rooms and known C. diff rooms alone.

The following HTWD practices were adopted on the SMUCLA oncology unit:

• Store Clorox germicidal bleach wipes in every patient room and at nursing stations.
• Nurses and care partners wipe down high-touch surfaces with bleach wipes once a shift for all patients and twice a shift for neutropenic patients.
• Wipe down all high-touch areas, including the bed frame, call light, doorknobs, countertops, side table, nightstand, monitor cables, and workstations.
• Follow C. diff rates monthly to monitor effectiveness and results.

HTWD was initiated in the oncology unit in February 2015. The rate of CDIs per 10,000 patient days (PDs) decreased from 14.99 in 2014 to zero from February to July 2015. We exceeded our goal of a 50% reduction when comparing C. diff rates from 2014 to recent years. In 2016, just 6.1 cases per 10,000 PDs were reported, and the most current data from 2017 shows a further decrease to 3.4 cases per 10,000 PDs. The HTWD is simple and inexpen­sive but can be highly effective

Several barriers were identified upon adding HTWD to unit workflow. Oncology patients endorsed sensitivity to the smell of bleach, exacerbating symptoms such as nausea and diz­ziness. By offering aromatherapy or encourag­ing ambulation during HTWDs, patients were agreeable to using bleach wipes and eager to have HTWDs completed.

Feedback from staff included problems with skin irritation and uniform staining. The Association for Professionals in Infection Control and Epidemiology suggests the use of PPE when cleaning with bleach. Wearing masks, gowns, and gloves have been an effective solution for employee protection.

Finally, the lack of formal HTWD documentation posed a great challenge. Ongoing discussions to integrate HTWD into the electronic record ended due to concerns surrounding scope of practice. Oncology staff recognizes the importance of HTWD in protecting our patients and currently document completion on paper.

Baseline staff knowledge of C. diff prevention was assessed with a pre-survey, followed by a tailored education plan and a subsequent post-survey. The outcome was an overall improvement of staff understanding of HTWD. Employees were edu­cated with informational flyers and a PowerPoint presentation during huddles, staff meetings, and annual skills labs.

The success of the HTWD was recognized by the chief nursing officer and transformational lead­ership shared-governance Magnet council as a nursing best practice and a key strategy for the fiscal year 2017-2018. SMUCLA implemented HTWD in February 2017 after extensive interprofes­sional collaboration and planning with stake­holders. UPCs and unit leadership provided stan­dardized education materials, campaign flyers, and hands-on training for staff. C. diff rates will continue to be evaluated over time as HTWD is applied to the broad patient population within the organization.

Performing HTWD as part of a bundle dramati­cally reduced C. diff rates on a medical oncology unit. CDIs were eliminated for 6 months follow­ing the project’s initiation, during which time intensive education and daily reminders were given. Ramphal, Suzuki, McCracken, and Addai demonstrated a 60% increase in compliance with HTWDs through repeated training. As evidenced by fluctuating C. diff rates, continued education, peer-to-peer accountability, and a follow-up tool are essential to the sustainability of this practice. The oncology unit will begin a trial using ultravi­olet light audits next year to evaluate consistency and compliance.

New 2017 Joint Commission and CMS guide­lines have brought nosocomial CDIs to the fore­front of nursing quality indicators. Incorporating nurse-driven environmental cleaning into hospi­tal-based infection control practices may provide the comprehensive program needed to decrease C. diff rates and improve patient outcomes in the acute care setting.

A previous version of this article can be found on OncNursingNews.com.