FOCUS ON INFECTION PREVENTION Data Snapshot: Clostridium difficile Infections in Long-Term Care Facilities JoAnn Adkins, RN, BSN, CIC Infection Prevention Analyst Pennsylvania Patient Safety Authority Clostridium difficile (C. diff) infection is a difficult-to-treat disease that may affect patients in healthcare facilities and can cause severe diarrhea and even death. C. difficile infec- tion (CDI) can be devastating to anyone, but it is especially worrisome in the elderly Upon its original publication in June 2016, because older people are more susceptible to developing CDIs and have a higher mor- this article contained statements and data repre- sentations in error. This current version includes tality rate.1 In the United States, more than 80% of the deaths associated with CDI corrections. occur in people age 65 or older. C. diff causes almost half a million infections yearly, with more than 100,000 occurring among residents in long-term care, making it one of the most serious healthcare complications for residents.1,2 Inappropriate or unnecessary antibiotic use and inadequate infection-prevention practices may increase the transmis- sion of C. diff in a facility and from one facility to another when infected patients are transferred.1,2 Although the incidence of CDI is decreasing in Pennsylvania long-term care facilities, diligence remains important because of the high incidence of CDI nationally and the significant mortality of CDI in elderly people. Between January 2010 and December 2015, Pennsylvania long-term care facilities (LTCFs) reported 13,100 CDIs to the Pennsylvania Patient Safety Authority. The CDI rate in Pennsylvania LTCFs in that period shows modest yearly decreases with an over- all decrease of 16% (Figure 1). The Southcentral and Southwest regions had higher rates of CDI than the other regions of the state for the period January 1, 2010, through December 31, 2015. The Table lists CDI rate by region. The Northeast region had an increase in CDI from baseline year of 2010 compared with 2015; however, it has had consistently low rates. The other five regions had decreases in CDI, with the Southcentral and Northwest regions having the most significant decreases (Figure 2). Strategies to reduce and prevent CDI in LTCFs include a combination of antimicrobial stewardship and infection-prevention practices. Prudent use of antibiotics is necessary because antibiotic exposure is a major risk factor for the acquisition of C. diff. This Figure 1. CDI Rates in Pennsylvania Long-Term Care Facilities, as Reported to the Pennsylvania Patient Safety Authority, 2010 through 2015 INFECTION RATE PER 1,000 RESIDENT DAYS 0.12 0.103 0.100 0.099 0.098 0.10 0.086 0.083 0.08 0.06 0.04 0.02 0.00 2010 2011 2012 2013 2014 2015 MS16406 YEAR CDI, Clostridium difficile infection. Page 74 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority Table. CDI Rates in Pennsylvania Long-Term Care Facilities by Region, as Reported to the includes avoiding antibiotic therapy Pennsylvania Patient Safety Authority, 2010 through 2015 (N = 13,100) when it is not indicated, such as for CLOSTRIDIUM DIFFICILE INFECTION asymptomatic bacteruria, and selecting REGION RATE PER 1,000 RESIDENT DAYS narrow-spectrum antibiotics that are associ- Region 1 – Northeast 0.07 (n = 1,393) ated with a lower CDI risk.3-5 Tools to help facilities develop antibiotic stewardship Region 2 – Southeast 0.07 (n = 3,715) programs are provided in the Pennsylvania Region 3 – Northcentral 0.11 (n = 878) Patient Safety Advisory articles “Antibiotic Region 4 – Southcentral 0.13 (n = 2,607) Stewardship in Hospitals and Long-Term Care Facilities: Building an Effective Region 5 – Northwest 0.10 (n = 1,451) Program”4 and “Strategies to Turn the Region 6 – Southwest 0.12 (n = 3,056) Tide against Inappropriate Antibiotic Utilization.”5 Infection-prevention prac- tices are important to reduce transmission. C. diff forms spores that are resistant to many commonly used disinfectants and to the bactericidal effects of alcohol. Figure 2. Changes in CDI Rates in Pennsylvania Long-Term Care Facilities, as Reported to the Pennsylvania Patient Safety Authority, 2010 through 2015 Effective infection prevention practices include: INFECTION RATE PER 1,000 RESIDENT DAYS —— Hand hygiene 0.18 —— Immediate implementation of full 0.16 barrier contact precautions for 0.14 patients with CDI 0.12 —— Environmental cleaning with sodium 0.10 hypochlorite (bleach) or a sporicidal 0.08 disinfectant approved by the Envi- 0.06 ronmental Protection Agency (EPA) 0.04 —— Identification and testing of 0.02 residents with diarrhea for CDI, 0.00 especially if they have had recent 2010 2011 2012 2013 2014 2015 antibiotic therapy Region 1—Northeast 0.06 0.07 0.08 0.08 0.08 0.07 —— Communication with transferring Region 2—Southeast 0.08 0.07 0.08 0.08 0.07 0.07 facilities if a resident has a CDI —— Education of staff, residents, and Region 3—Northcentral 0.12 0.11 0.09 0.12 0.10 0.11 visitors1-3,6-9 Region 4—Southcentral 0.13 0.17 0.13 0.13 0.12 0.10 CDI is a serious disease that can cause significant morbidity and mortality, espe- Region 5—Northwest 0.11 0.12 0.13 0.11 0.07 0.07 cially in the elderly. Using appropriate Region 6—Southwest 0.13 0.13 0.11 0.11 0.11 0.11 antibiotics and implementing effective MS16701 infection-prevention practices along with YEAR active surveillance for potential CDI cases CDI, Clostridium difficile infection. can help facilities prevent transmission of C. diff. Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 75 ©2016 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION NOTES 1. Centers for Disease Control and Preven- an effective program. Pa Patient Saf Advis 7. Goudarzi M, Seyedjavadi S, Hossein tion (CDC). Vital signs. Making health 2015 Jun [cited 2016 Jan 11]. http:// Goudarzi H, et al. Clostridium difficile care safer - stopping C. difficile infections patientsafetyauthority.org/ADVISORIES/ infection: epidemiology, pathogenesis, [online]. 2012 March [cited 2015 Dec 15]. AdvisoryLibrary/2015/Jun;12(2)/ risk factors and therapeutic options. Sci- http://www.cdc.gov/vitalsigns/HAI/ Pages/71.aspx entifica (Cairo) 2014;2014:916826. http:// StoppingCdifficile/index.html 5. Adkins J, Bradley S, Finley E. Strategies to www.hindawi.com/journals/scientifica/ 2. Stone N. Dying from C. diff: who is most turn the tide against inappropriate antibi- 2014/916826/ vulnerable? [online]. Medscape 2015 June otic utilization. Pa Patient Saf Advis 2015 8. Gould C, McDonald LC. Bench-to- 2 [cited 2016 Jan 11]. http://www.med Dec [cited 2016 Jan 11]. http://patient- bedside review: Clostridium difficile scape.com/viewarticle/845534 safetyauthority.org/ADVISORIES/ colitis [online]. Crit Care 2008;12(1):203 3. Chopra T, Goldstein E. Clostridium dif- AdvisoryLibrary/2015/Dec;12(4)/ [cited 2016 Jan 11]. http://ccforum.com/ ficile infection in long-term care facilities: Pages/149.aspx content/12/1/203 a call to action for antimicrobial steward- 6. Dubberke E, Carling P, Carrico R, et al. 9. Stokowski L, McDonald LC. Refining our ship. Clin Infect Dis 2015 May 15;60 Suppl Strategies to prevent Clostridium difficile approach to Clostridium difficile preven- 2:S72-6. infections in acute care hospitals: 2014 tion [online]. Medscape 2012 Mar 21 4. Bradley S. Antibiotic stewardship in hospi- update. Infect Control Hosp Epidemiol 2014 [cited 2016 Jan 11]. http://www. tals and long-term care facilities: building Sep;35 Suppl 2:S48-65. medscape.com/viewarticle/760505 SAVES, SAFETY II, AND SYSTEM IMPROVEMENTS This narrative introduces a new occasional feature of the Pennsyl- problem and sent the faulty container back to pharmacy. The vania Patient Safety Advisory, highlighting successes by healthcare pharmacist and the RN collaborated on checking the other workers in keeping our patients safe. Safety-II is an approach that doses in the cabinet. They found that the other doses in the assumes that everyday performance variability provides the adap- drawer were correct; each contained one 50 mg pill per con- tations that are needed to respond to varying conditions, and tainer. The RN administered the correct dose to patient. that humans are a resource for system flexibility and resilience. This has been identified as a good catch of a dosage error, based The safety management objective is to understand and facilitate on information available in the event narratives in the Pennsylva- everyday work and to maintain the adaptive capacity to respond nia Patient Safety Reporting System. The Authority recognizes and effectively to inevitable surprises.1 System improvements seek to applauds the RN and pharmacist for identifying the mislabeled optimize the complex systems that surround and integrate with container, realizing that the error could affect more than one healthcare workers’ efforts to provide safe patient care. container, and taking the time to check the additional containers. Twice as Much Isn’t Twice as Good Note Fifty milligrams of a medication was prescribed for a patient.* 1. Hollnagel E, Wears RL, Braithwaite J. From safety-I to safety-II: a When the patient’s registered nurse (RN) pulled the medica- white paper. The Resilient Health Care Net: Published simultaneously tion out of the automated dispensing cabinet, there were 2 by the University of Southern Denmark; University of Florida, USA; pills, each 50 mg, inside the container, equaling 100 mg, and Macquarie University, Australia. 2015. Also available on Inter- however the label said 50 mg. The RN did not administer net: http://resilienthealthcare.net/onewebmedia/WhitePaperFinal.pdf the med at this time but called the pharmacy to report the *The details of the PA-PSRS event narrative in this article have been modified to preserve confidentiality. Page 76 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 2—June 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://www.patientsafetyauthority.org. An Independent Agency of the Commonwealth of Pennsylvania ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 50 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. 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