Reducing Hospital-Acquired Clostridium difficile on a Medical-Renal Unit

Providence St. Peter Hospital
Olympia, Washington, USA

Providence St. Peter Hospital participated in the IHI Learning and Innovation Community on Reducing Hospital-Acquired Infections.

Gerda Barlow, RN, Quality Improvement Specialist
Tre Fortner, Environmental Services Supervisor
Joan Harrod, RN, ICP
Liz Hopkins, RN, BSN
Jim Leonard, Chief Executive, Team Sponsor
Ed Micas, Manager Environmental Services
Carol O’Hare, RN, BSN, Medical-Renal Unit
Seth Thaler, MD, Medical Champion

Our aim was to reduce hospital-acquired Clostridium difficile infections (CDI) by greater than or equal to 30 percent by October 1, 2008, on the Medical-Renal (Med-Renal) unit by focusing on hand hygiene, contact precautions, and environmental cleaning and disinfection. Our new aim is to decrease CDI by greater than 30 percent hospital-wide within two years (by October 1, 2010).

  • Percent of patients with hospital-acquired Clostridium difficile associated disease
  • Days between hospital-acquired cases of Clostridium difficile on the Med-Renal unit
  • Percent of occupied patient rooms with complete environmental cleaning of high touch surfaces
  • Hand hygiene (HH) compliance as percent (number of appropriate HH observations in a patient encounter divided by the number of patient encounters, multiplied by 100)
  • Percent of patient encounters with compliance for contact precautions (CP)
  • Percent of patient encounters in which the preprinted isolation order (PPO) was used

The team improved hospital-acquired Clostridium difficile (C. diff) rates on the Med-Renal Unit by implementing IHI’s key strategies for preventing infection transmission. These strategies focused on hand hygiene, contact precautions, and environmental cleaning.
Key changes included:
  • Started program of designated unknown observers (“secret shoppers”) for auditing hand hygiene compliance 
  • Shared data transparently on the pilot unit
  • Developed a preprinted nursing isolation order and spread use of this hospital-wide
  • Created an Environmental Services (EVS) occupied room checklist
  • Implemented new color coded isolation STOP signs
  • Began use of bleach for terminal cleaning from known C. diff patients




Summary of Results / Lessons Learned / Next Steps
Focusing on environmental cleaning in occupied patient rooms, hand hygiene, and contact precautions had a substantial impact on our pilot unit. The hospital-acquired C. diff rate fell from a baseline rate of 0.57 percent to an overall mean of 0.34 percent, a 40 percent reduction in 18 months. In addition, the pilot unit experienced a stretch of 235 days without a CDI.

With the use of a checklist, disinfection of high touch surfaces in occupied patient rooms reached and was sustained at 95 percent. By auditing hand hygiene practice using an unknown observer and making the data transparent, the overall hand hygiene rate averaged >80 percent. Simplifying the isolation cart process, changing isolation STOP signs, and instituting a preprinted isolation order supported and clarified expectations for contact precautions. However, opportunities to adhere to all components of contact precautions remain.
Lessons Learned:
  • Staff benefit from ongoing education, communication, and updates about data to remain engaged. Continued measurement and rounding yield positive effects.
  • Direct observation is the best method for measuring hand hygiene compliance. Ongoing observations are more useful than intermittent data collection. Having HH observers work together to increase inter-rater reliability is helpful, as is working across shifts. 
  • Streamlining the isolation cart process improved access to needed isolation supplies.
  • Essential team members included Environmental Services, process improvement facilitation, and front-line staff. Positive results require teamwork.
  • Limiting the areas of focus allows enough energy and time to be dedicated to improvement efforts. Similarly, designing small tests of change and expanding in small increments created more enduring change.
  • By asking staff to provide positive feedback to each other when they see appropriate hand hygiene, we uncovered a barrier in our culture: the culture did not support this kind of healthcare-worker-to-healthcare-worker interaction.
  • Hand hygiene is a project unto itself.
  • Assigning process ownership facilitates the spreading of the changes.
  • Changing MD practice around hand hygiene remains a big challenge.
  • Too few front-line nursing staff for planning tests of change.
  • Change in personnel on pilot unit (health care unit coordinator and EVS staff) created delays for retraining.
  • Making data collection for hand hygiene and contact precautions a high priority. The data are difficult to collect when primary job duties are maximized and staffing is in short supply.
Next Steps:
  • Secure/justify increased hours for Environmental Services to continue occupied room disinfection and continue spread of EVS checklist to most inpatient units.
  • Work with IS to use screen savers on units for data display and continue to share data hospital-wide. Present outcomes to various groups within organization to support spread.
  • Assign nursing to collect data for contact precautions on all nursing units and continue work to improve hand hygiene compliance.
  • Hardwire the work. Transition from “our work” to “your responsibility.”


Contact Information
Lou Hilken, RN, MN
Providence St. Peter Hospital

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