In this interview with IHI Communications Specialist Jo Ann Endo, IHI faculty member Brian Koll, MD, FACP, FIDSA, says that effectively addressing C. diff requires true multidisciplinary teamwork. Dr. Koll is Executive Director for Infection Prevention at the Mount Sinai Health System in New York, NY.
Q: A number of healthcare-associated infections appear to be on the decline. Why isn’t this the case with C. diff?
When one looks at healthcare-associated infections, dealing with C. diff is a little different than what we’ve been able to do to prevent catheter-associated UTIs or central line-associated bloodstream infections, or even ventilator-associated pneumonia, where there is a discrete group of evidence-based practices that can be instituted to reduce those infections.
C. diff is a completely different animal. For example, because it is a spore-forming organism, it’s harder to eradicate from the environment. Also, we are colonized with C. diff, so when we come into the hospital and we need antibiotics, it disrupts the microbiome and C. diff is able to prosper and cause disease.
The spore itself is becoming more resistant to therapy, and as patients are going from the inpatient setting to the outpatient setting, to possibly a skilled nursing facility or a rehab facility, all of those parts of the health care system play a part in infection prevention.
The control of C. difficile involves all levels of staff. In addition to physicians, nurses, nurse practitioners, and physicians’ assistants, you need to engage your pharmacist, implement antimicrobial stewardship, and look at the use of things like proton pump inhibitors. We need to engage our housekeepers and our transporters. This involves the entire health care system and it’s hard for such a large group to march in the same direction.
Q: Why is it necessary to engage a wide array of disciplines and staff members in this work?
In our system, we are in the process of building what we call physician-nurse dyads who will be the leaders for each area of the hospital. As the dyads were getting established, we realized that what we really need are triads — a physician-nurse dyad plus another person in environmental services, the pharmacy, or transport.
We’ve also realized that it’s important to engage the people I’ll call “non-clinicians,” and help them understand the role they play in the prevention of disease. This includes cleaning to disinfect the rooms and eradicate the spores from the environment. We use a range of tools in a positive, non-punitive way to show the importance of what we’re calling environmental hygiene.
Our hospital uses the tiered approach to environmental hygiene that’s been recommended by the Centers for Disease Control and Prevention (CDC). This starts with a checklist to be sure we’re all in agreement about not just what needs to get cleaned, but also who is responsible for cleaning. In certain areas, nursing staff are responsible for cleaning particular items in a room. Our housekeepers are responsible for cleaning other items in a room. In the OR, anesthesia may be responsible for cleaning their carts. Dietary is responsible for cleaning specific things. So, we use a checklist to delineate those responsibilities.
The dyads and triads are going to be very helpful because we want them to be partners with infection prevention. Preventing C. diff and other healthcare-associated infections should not be something for which infection prevention staff are solely responsible.
We also need to make sure we educate patients so they understand they don’t always need an antibiotic. Every antibiotic increases your risk of C. difficile. Sometimes antibiotics are necessary, but it’s always a balance. Clinicians no longer just need to figure out the correct antibiotic and the correct indication. Some of the evidence is beginning to suggest that looking at the duration of antibiotics is also important — to see if “less is more” and you’re able to minimize the disruption to the bowel’s bacteria, but also cure the infection. For example, when I was in medical school, we used to treat kidney infections for two to three weeks. We really don’t do that anymore because we’ve learned over time how to select appropriate antibiotics and treat for shorter durations.
Q: Will you describe the non-punitive approach to engaging people in their infection prevention role?
We try to be positive and focus on teaching and learning moments, and to constantly assess our system. There is very good data which show that if you go into a facility and receive care where the prior person either had MRSA or C. difficile, your risk of getting those infections greatly increases. Over time, as we have seen improvements in our cleaning, we’ve seen our C. diff rates go down. What we’re trying to do is set discrete targets, so that if our current C. diff rate is seven per 10,000 patient days, by the end of the year we want our rate to be 3.5 per 10,000 patient days.
Q: A 2013 study in the New England Journal of Medicine seemed to challenge the conventional wisdom about how C. diff is transmitted and the profile of the “typical” patient with C. diff. How does this align with what you’re seeing?
In New York, we’ve reported C. difficile data to the New York State Department of Health since around 2009. What struck all of us is that there is variation of community-onset C. difficile and there now seems to be a lack of traditional risk factors. People with C. diff are not necessarily elderly. They’re not necessarily people who are frequently in the health care system. C. diff is also being seen in young, healthy adults and teenagers.
As people are discharged from the hospital or a skilled nursing facility and return to their home environment, if they still have C. diff then obviously the risk to others in the home is greatly increased. It’s also interesting to see the research on the microbiome and the good, evidence-based data on what we’re doing to [our body’s] internal environment, and how to re-create its balance. The use of probiotics is being looked at again in a completely different way. Even the data for fecal transplants seems to support restoration of that balance.
Q: What have been the keys to success for organizations that have made reductions in C. diff?
It all starts with senior leadership because they set the tone — your chief executive officer, chief nursing officer, chief medical officer, and president of your facility. They help to make these efforts positive, not punitive, and to talk about C. diff prevention in terms of reduction in patient harm and patient safety because no one who works in health care wants to do anything to hurt or harm a patient.
Number two, for us, has been partnering closely with the health care union to teach about infection prevention, concentrating on hand hygiene and the environment of care. We have a workforce that is so eager to help protect our patients from harm. It’s been important for us to work together to develop a system to help people understand how their work relates to C. diff prevention.
Dr. Koll and Don Berwick in 2007
Q: Why is reducing C. diff so important from the patient’s perspective?
From a patient perspective, C. difficile has a profound effect on morbidity and mortality. With C. diff, you have severe diarrhea that may not go away for a period of time. Imagine five days of diarrhea, and what that does to you. You’re weak, you’re tired. If you’re in the hospital, it’s going to increase your length of stay. To get better, we try antibiotics that are not easy to take. Fecal transplant is another way to manage C. diff, and I think most folks have a pretty visceral reaction when they hear about it. If C. diff is severe, it can predispose us to secondary infections because it damages our bowels.
You can have malabsorption, you can have bacteria escaping from our bowels into our bloodstream, and it could also cause what’s called toxic megacolon. At that point, the spores are beginning to create a reaction that sort of kills the colon. If one has to go for surgery, part of the colon may need to be removed, and the mortality rate with that can be as high as 50%.
Also, with C. diff you can get you better, but there’s also a chance of recurrence. The recurrence rate can be as high as 25% to 30%.
Q: How does addressing C. diff complement the work that a lot of organizations are doing to reduce costs while they’re improving quality and safety?
When we work with health care providers, we don’t approach any type of infection first as a financial issue. We approach it as a patient safety component. We may talk a little bit about length of stay, but we’re primarily focused on morbidity and mortality. Infection prevention is not necessarily a money maker; it is a money saver, in addition to saving people’s lives. It’s much more effective to put resources into preventive efforts instead of reactive efforts.
Q: Why will your team make a point of focusing one of the IHI Expedition sessions on transitions and long-term care?
It’s not news to anyone that patients who come to the hospital are now sicker than they were in years prior. They’re coming in acutely ill, and we’re able to make them better, but they may go home with a visiting nurse or with the help of family members. Many folks go to some sort of skilled nursing facility or rehab center to complete their care.
Since patients are often going elsewhere upon hospital discharge to complete their care, it’s important that we communicate with each other. If somebody’s leaving my facility with C. difficile, I don’t want that person going to another facility and spreading it. We all play a role in that communication and prevention effort — whether in the inpatient setting, outpatient setting, or home care setting. I’ve taken care of family members at home, so I know that a big challenge is how to impart the necessary knowledge to family members when a patient returns home. We have to teach family caregivers how to protect themselves as they provide care for their loved ones.
Q: What has surprised you most in your efforts to prevent C. diff over the years?
What has really impressed me is how the non-clinicians have risen to this task. I’m glad the importance of their roles in keeping patients safe has been recognized. I think they’ve found that gratifying and it’s helped build the teamwork here.
When I started as a medical student in the 1980s, there was a true team approach and I think we lost track of that. It’s coming back now, which is very important. I think we’ve got it here [at Mount Sinai], and it sounds like many other places do also. And I have to say part of that is through the efforts of IHI.
We’re a teaching institution, so we include our nursing students, administrative interns, pharmacy interns, and medical students (so it’s even prior to when they’re residents) in our safety efforts. They need to feel they have a role in infection prevention because they’re going to be our future leaders.
I don’t think it makes a difference if you’re in a large organization or a small one. Everyone has a part to play when it comes to reducing harm to patients.