Targeting C. difficile reductions

For all the progress that has been made on reducing health care-associated infections — and we've seen progress on many fronts — significantly moving the needle on Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) rates has proven difficult.

This point was underscored again in late March when the Centers for Disease Control and Prevention released its "National and State Healthcare Associated Infections Progress Report".

The 124-page document noted a 4 percent drop in hospital-onset MRSA bloodstream infections between 2011 and 2012 and a 2 percent decrease in hospital-onset C. difficile infections during the same period. While this incremental progress is encouraging, the CDC notes that the reductions in C. difficile were well below the 25 percent target goal for 2013.

Conversely, the report highlighted far greater improvement in cutting central line-associated bloodstream infections (CLABSI), which dropped 44 percent between 2008 and 2012; and in 10 surgical procedures that were tracked, surgical-site infections were down 20 percent between 2008 and 2012.

It's always dangerous to read too much into statistical data and the reasons why there has been much greater progress in one type of infection than another, but one can safely say there hasn't been the same sort of highly coordinated national education effort and evidence-based, action-oriented push to cut C. difficile rates the way there has been on, say, reducing CLABSI in intensive care units (ICUs).

In the case of CLABSI, a focused decade-long effort by researchers, educators, infection prevention organizations and governmental groups had much to do with the ensuing 63 percent decrease in the number of ICU patients suffering a CLABSI event between 2001 and 2009.

Peter J. Pronovost, M.D., the noted intensive care specialist physician at Johns Hopkins Hospital and patient safety advocate, played a lead role in developing and introducing an ICU checklist protocol for clinical teams to employ in the Keystone ICU Project on hospital mortality. During an 18-month period, the initiative saved an estimated 1,500 lives and $100 million in Michigan.

Pronovost and many colleagues then worked tirelessly to develop and disseminate this checklist and to teach hospitals across the country the evidence-based protocols that played a key role in the sharp reductions in CLABSI rates in 95 study hospitals in Michigan. Undoubtedly, these efforts contributed significantly to the documented long-term reductions in CLABSI rates that were noted in the recent CDC progress report.

Such efforts aren't easy or inexpensive, but the results speak for themselves. One might conclude that it's going to take a similar type of laserlike focus and national education campaign to get the same kind of reduction in C. difficile and MRSA rates.

The education will need to be broad-based and include physicians and other clinical team members as well as infection prevention specialists. And without question, the role of environmental services (ES) professionals will need to be considered to achieve the types of reductions being targeted at C. difficile by the CDC and others.

To be sure, many factors have led to the more than twofold increase in the number of C. difficile discharges in the United States between 2000 and 2011, as reported by the Agency for Healthcare Research and Quality. Overprescribing antibiotics to patients is among the primary culprits.

But if C. difficile rates are going to fall significantly, greater attention also will need to be paid to the positive role that ES teams can play in this effort and in ensuring that they have the education, training, manpower, time and resources to effectively combat C. difficile in patient care environments.

Many ES teams around the nation have had great success in reducing C. difficile rates by developing targeted, standardized cleaning and disinfection protocols, comprehensive training programs, consistent teamwork with their infection preventionists and by monitoring and measuring cleaning thoroughness.

Likewise, technologies such as ultraviolet light disinfection and hydrogen peroxide vapor systems are showing promise in many institutions when targeting health care-associated infections, although clearly many researchers still want to see more broad-based, peer-reviewed research on the efficacy of these technologies in hospital settings.

In the meantime, ES directors must remain steadfast in their commitment to evidence-based education, training, monitoring and measuring cleaning and disinfection efforts in conjunction with their infection control professionals to achieve greater progress in reducing C. difficile.

If they do and we see a more concerted national effort on this issue, we'll see the needle bending more significantly toward the 25 percent reduction of C. difficile that CDC and others are targeting.

Bob Kehoe is the associate publisher of Health Facilities Management. He can be reached at rkehoe@healthforum.com.