With all the horror stories published about Clostridium difficile (C. difficile or C. diff.), how can anything be positive about this infection? After all, C. difficile is the most important cause of health care-acquired diarrhea and has tripled the number of hospital stays in the past 10 years. It is specifically harmful to the older patient and is usually spread while the patient is in the hospital and nursing care center.
The Bad News
Clostridium difficile is an anaerobic bacterial spore that may be present in normal bowel flora of about 3 percent of the adult population and over 66 percent of infants, according to Public Health England. When patients are given antibiotics, the normal bowel flora that keeps C. diff in balance is weakened or killed by the antibiotics. That is when C. diff begins to flourish and produce harmful toxins.
A patient with a C. diff infection will experience diarrhea that contains the toxins of the C. diff bacterium. This infection can spread by contact with room surfaces—such as bed linens, bed rails, side tables, sinks, bed pans, or wash basins—and the clothes and hands of health care workers. C. difficile is very resistant to common hospital disinfectants and alcohol-based hand sanitizers, and has unfortunately developed more resistant strains since it was discovered as a cause for hospital-acquired infections.
A quick look at the facts as reported by the Centers for Disease Control and Prevention (CDC) as of March 2012 shows that:
■ About 25 percent of C. difficile infections first present in hospitals; about 75 percent present in nursing homes.
■ Twenty percent of the most severe C. difficile infections can reoccur.
■ C. difficile is linked to 14,000 annual deaths in the United States and an additional $1 billion of health care dollars spent.
■ Half of the infections occur in patients younger than 65, but more than 90 percent of C. difficile deaths occur in patients 65 and older.
■ Half of all hospital patients with C. difficile were admitted with the infection, known or unknown.
■ Diarrhea is the most dangerous way C. difficile can spread.
■ Information regarding the patient’s infection and treatment is not transferred to the nursing home, home health agency, or family, setting up an opportunity for reinfection.
So What Is The Good News?
This infection is preventable by implementing focused prevention protocols defined by CDC in its “CDC Vital Signs,” March 2012. If a patient has been diagnosed with C. difficile or the person has had at least three unformed stools in a short period of time, use the “when in doubt, rule it out” process.
The following are simple steps to take for infection prevention:
■ Use antibiotics judiciously.
■ Move the patient to a private room, and follow universal precautions to include gowns and gloves during patient care. Contain used linens in secured plastic bags before moving to them to the general laundry area.
■ Wear gown and gloves before entering the room of a patient with diarrhea or a known C. difficile infection, and wear them for all visits to the room. As nursing staff are well aware, their plans may be disrupted with what the patient needs at any given moment, so always be prepared for contact.
Afterward, be sure to remove the gown and gloves correctly: gown first, folding inside out, then gloves, grabbing the outside of the glove and rolling off the hand inside out. All done, right? Not quite.
■ All persons who come in the patient’s room should wash their hands with soap and water before leaving the room. Remember: C. difficile spores are resistant to alcohol, so the alcohol-based hand sanitizers are less effective. Stop, lather, and rinse with soap and water. Now the caregiver is clean, but what about the room?
■ Environmental personnel should wipe surfaces with an Environmental Protection Agency (EPA)-rated disinfectant with a sporicidal claim per instructions for use or a 10 percent sodium hypochlorite solution, in other words, an old-fashioned bleach solution. This 1:10 bleach solution can be found in many commercially prepared solutions and wipes.
Remember: All surfaces potentially contaminated with C. difficile need to be cleaned while the patient is occupying the room, and then as a terminal clean at discharge. This cleaning may include bed and mattress, bed rails, call buttons and TV remotes, bedside tables, over-bed tables, wash basin, and bed pan, just to name a few. Don’t forget about the sink and faucet handles.
■ Patients will want to participate in prevention, too. Instruct them to use only their own bathroom for toileting and wash their hands well with soap and water afterward. Offer them hand washing at the bedside with a basin, soap, and water, if needed.
Change soiled gowns and linen immediately, and wash any surfaces—such as the bed frame or rails—that may have become contaminated with EPA-approved surface wipes with a sporicidal claim or a 1:10 bleach solution.
■ Nurses should record and transfer the care plan to the next facility or caregiver, specifically calling out that the patient is actively being treated or was treated for a C. difficile infection. Community health organizations may also need information to record the infection and treatment utilized.
Regularly reference publicized information to make sure the nursing center is equipped with the most up-to-date gold standard prevention programs for C. difficile.
Research to improve care for those with C. difficile includes investigating the use of fecal transplants for patients with recurring C. difficile, the use of probiotics, and an experimental vaccine shown to be effective in protection against the C. diff toxins in animal models.
Be a leader in the fight to prevent the spread of C. difficile. Report and publish the facility’s success, and share your protocols with others to win the battle against C. difficile infections.
Lastly, take personal care. Remember to wear a gown and gloves before stepping into the room to care for the patient. Always wash hands with soap and water. Be aware of personal vulnerability if taking antibiotics and caring for sick patients. The well-being and knowledge of staff are the best defenses to an onset of C. difficile.
Sydney Nye, BSN, RN, MBA, is vice president of clinical services for Medline Industries. She has more than 30 years of hospital experience in the operating room and central processing. She has served in a variety of roles, including operating room staff nurse, perioperative director, and educator. Nye has developed expertise in medical device reprocessing and has designed numerous instrument sterilization trays for safe instrument management. She has authored numerous education booklets and provided workshops that highlight efficiencies in perioperative supply chain management and best practices in care and handling of surgical instruments.