1. Clostridium-Difficile Reduction Utilizing an Interdepartmental Team Approach

2. Objectives Demonstrate how APIE was used to facilitate solving our problem Discuss how our team approach helped to improve care, reduce C-Diff #s and make staff happier Discuss our hand washing monitoring program where staff monitor other staff

3. APIE Assess Plan Initiate Evaluate

4. Assess Problem Identify problem 1.Increase in cases 14 cases in 2007

5. Assess Problem Identify problem 1.Increase in cases 14 cases in 2007 18 CASES IN 2008 FROM JANUARY TO JUNE

6. Assess Problem Identify problem 1.Increase in cases 14 cases in 2007 18 cases in 2008 Jan – June 2.Time Line Indentify overlapping patients Indentify primary departments involved 3.Observe staff behavior Not isolating until after diagnosis Sharing commodes/toilets Carrying dirty laundry out of room to hamper

7. Plan 1.Target Zero Task Force – Interdepartmental RNs, CNAs, Education staff, and Environmental staff 2. Review Policy and Procedure 3.Meetings with Patient Care Staff/Environmental Staff

8. Implement 1. Revise Isolation Policies and C-Difficile Policy All patients with diarrhea on isolation until cleared Strict Contact Isolation Double bag linen and trash 2. Mandatory education classes for all patient care staff 3. Revise Terminal Cleaning Policy Expanded terminal cleaning Wall to floor Privacy curtains 4. Environmental Service education

9. Implement 5. Add 2 Environmental FTEs for full 24/7 coverage

10. Evaluate 1. Staff reactions and concerns Anger over number of isolation rooms Concern over increase in isolation PPE Concern/anger over extra time involved Concern by Environmental staff that Patient Care staff was not using proper technique 2.Revise Isolation Policy again 3.Listened to concerns of Patient Care staff and Environmental staff

11. Evaluate Decrease in C-Difficile numbers!!!!!

12. Immediate decrease in C-Difficile numbers 2007 – 14 cases/21796 X 10000 = Rate 6.0 2008 - 22 cases/21631 X 10000 = Rate 10.0 18 cases in 1 st 6 months 4 cases in 2 nd 6 months 2009 - 11 cases/20674 X 10000 = Rate 5.0 2010 - 8 cases/20255 X 10000 = Rate 4.0

13. 2011 Changes New Policy and Procedure Including definition of diarrhea Reemphasize when testing can be done Decrease in Isolation time Developed algorithm for C-Dif isolation

14. Patient has loose stool Initiate Contact Isolation No diarrhea or < 3 bouts in 24hs 3 or > loose stool In 24 hours d/c isolation d/c stool for toxin with MD order Obtain MD order for C-Diff toxin All cultures negative C-Diff positive Continue isolation Loose stools cease X 24 hrs Terminally Clean room D/C Isolation Note: If MD has ordered C-diff toxin and pt. has formed stool assess need for test with MD. Pt does not need isolation.

15. HAND HYGIENE MONITOR 2008 Hand Monitors –Done by managers –Good Results 87-94% –Questioned accuracy

16. HAND HYGIENE MONITOR 2009 Target Zero Task Force members offered to act as Secret staff monitors Rates dropped to: 71% Before care 86% After care 73% Before and after gloving

17. 2010 HAND HYGIENE MONITOR Target Zero Task Force developed a plan to have the staff monitor each other. –More accurate if done properly –Learn as they observe

18. Employees monitoring employees Overcome: Feeling that they are spying on their colleagues Prejudice in reporting – either all good or really bad –education WE DO NOT ENTER OBSERVED EMPLOYEE’S NAME

19. Employee Monitors Two a month by all patient care employees –Increase # of monitors Open monitor through icon on pc desktop (excel program) –Enter date, Dept., observer’s initials, type of employee monitored, and answer 4 questions Did he/she wash hands before contact Did he/she wash hands after contact Did he/she wash hand before gloving Did he/she wash hands after gloving

20. Hand Hygiene Monitor 2010

21. SUCCESS STORY??? NOT YET!!! 2 week quick review could not replicate data Need re-education Need more encouragement Infection Prevention needs to meet with staff frequently