Welcome and Overview

With use and overprescribing of antibiotics, there are certain bacterial infections that increase, including C. difficile. This session will discuss strategies to prevent and track incidence and prevalence of C. difficile infection in nursing homes.

This session is one of a series of six sessions for nursing homes to support implementation of principles and practices of antibiotic stewardship and prevention and management of C. difficile infections.

 Objectives

• Use strategies to prevent C. difficile.
• Use strategies to track and monitor C. difficile.

 How can you use this session?

This session focuses on strategies to prevent, track, and monitor C. difficile infections in nursing homes. The material is intended to be useful for guiding individual practice and as an educational resource for staff involved in the care of nursing home residents. Nursing home leaders can review the content in this session and decide which components would be helpful to staff in their facility. The components can be shared and discussed during staff education sessions, or they can be accessed by staff online at any time.

Depending on which components you choose to review and/​or share and discuss with staff, this session may take 30-90 minutes.

 Orientation

Here is an outline of what is in this session. You can click on the hyperlinks to go directly to a section or scroll down below the outline to see all section content.

 What actions can be taken to prevent and manage multi-drug resistant organisms and C. difficile in nursing homes?

Before we jump into outlining the actions that caregivers should take to minimize the spread of MDROs and C. difficile, you may find a review of the organisms and how they spread in healthcare settings helpful. Understanding how these organisms emerge and spread provides important information to help staff change behavior or implement new practices. Watch Parts 1 and 2 of the webinar if desired, and then view Part 3. 

Watch these webinars presented by Nimalie Stone, MD, MS, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC:

Taking Action to Prevent and Manage Multidrug-resistant Organisms (MDROs) and C. difficile in the Nursing Home:

    Part 1 – Reviewing the organisms (15:02)

Part 1 covers basics on bacteria, common bacteria in healthcare, antibiotics 101, understanding multi-drug resistance, and how nursing homes are reservoirs of MDROs and C. difficile infections with onset in nursing homes.

For the presentation slides: PDF

For the presentation transcript: PDF

    Part 2 – Understanding the spread (14:52)

Part 2 covers healthcare drivers of C. difficile and MDRO development and spread including antibiotic pressure and medical devices and wounds, colonization pressure, resident to resident transmission via hands of healthcare personnel, and contamination of shared environment/​equipment.

 For the presentation slides: PDF

 For the presentation transcript: PDF

    Part 3 – Strategies to prevent (23:51)

 Part 3 covers consistent performance of hand hygiene; appropriate use of gowns and gloves; resident        placement principles, strategies, and considerations; and environmental cleaning.

For the presentation slides: PDF

For the presentation transcript: PDF

NOTE: A 64-minute version of this webinar series, originally presented by Dr. Stone for the American Association of Nurse Assessment Coordination (AANAC), can be found in the Optional Tools and Resources list.

 What are your rates of C. difficile in your building? How do you know?

CDC’s National Healthcare Safety Network (NHSN)

One resource to document and track rates of C. difficile is through the CDC’s National Healthcare Safety Network (NSHN), which provides long-term care facilities with a customized system to track infections in a streamlined and systematic way. When facilities track infections, they can identify problems and track progress toward stopping infections. On the national level, data entered into NHSN will gauge progress toward national healthcare-associated infection goals. NHSN’s long-term care component is for use by nursing homes, skilled nursing facilities, chronic care facilities, and assisted living and residential care facilities.

Access more information from NHSN on tracking infections in long-term care facilities here.

National Nursing Home Quality Improvement Campaign (NNHQIC) Data Tracking Tool for Monitoring C. difficile Infections

If your organization is not ready to document and track rates of C. difficile through the CDC’s National Healthcare Safety Network (NSHN), consider the NNHQIC data tracking tool for monitoring C. difficile infections.

For more information about the NNHQIC C. difficile infection tracking tool and prevention resources, see these educational videos and webinars about the infection goal.

Please be mindful that data submission on the NNHQIC website is not a substitute for submission into the NHSN database. While the NNHQIC tool does use the CDC’s laboratory-based surveillance method and definitions, the data entered in the NNHQIC website are not forwarded to NHSN to gauge progress toward national healthcare-associated infection goals.

Infection Surveillance Line List

If a nursing home chooses not to use NHSN or the NNHQIC C. difficile infection tracking tools, another option would be to use an infection surveillance line list such as the one listed below. However, the use of an infection surveillance line list then requires you to interpret the data in order to understand your rates of C. difficile infection.

Here are more resources from the Minnesota Department of Health:

• Appendix K: Infection Surveillance Definition Worksheet (PDF)
• Appendix L: Instructions for Completion of the Long-term Care Infection Tracking Tool (PDF) | Infection and Antibiotic Use Tracking Tool (Excel)

NOTE: These tools are also used in the session Antibiotic Stewardship.

 Activity

Identifying and Improving C. difficile Prevention Practices

Using probing questions can guide you and your team in understanding whether C. difficile is an issue within your facility and which prevention practices you might want to work on first. The tools used in this activity were developed to assist nursing homes in exploring a series of questions – a guided root cause analysis to stimulate thoughtful discussion on places where there may be opportunities for improvement.

 Access the National Nursing Home Quality Improvement Campaign's probing questions here.

Action items:

1. Work through the probing questions as a team and identify an area of opportunity.
2. Review and complete the Assessment of Current CDI Prevention Activities.
3. Discuss the findings from your assessment with your quality assurance and performance improvement (QAPI) team. 
   • What do you already do well?
   • Where are your opportunities?
   • What might be the hardest pieces for you to implement and why?
   • Prioritize 1-2 specific prevention actions that you want to implement.
4. Identify next steps and resources needed to implement the specific prevention actions that you prioritized.

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    Take Home Messages

• C. difficile spores are shed in feces. Any surface that becomes contaminated with feces may serve as a reservoir for the C. difficile spores.
• C. difficile spores are transferred to residents/​patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item.
• C. difficile infections can be prevented by using infection control recommendations and more careful antibiotic use.
• Everyone in the nursing home plays a role in preventing C. difficile infection.

• When facilities track infections, they can identify problems and track progress toward stopping infections.

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  Optional Tools and Resources

 Reducing C. difficile Infections Toolkit: Best Practices from the GNYHA/UHF C. difficile Collaborative

This resource includes sections on why to focus on C. difficile, getting started, data collection strategies, and jk./tools and sustaining practices.

AHRQ Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship

The Evaluation and Research on Antimicrobial Stewardship​'s Effect on Clostridium difficile (ERASE C. difficile) Project toolkit was developed to assist hospital staff and leadership in developing an effective ASP with the potential to reduce C. difficile. This resource was prepared by Boston University School of Public Health, Montefiore Medical Center, Greater New York Hospital Association/​United Hospital Fund.

 Resources for Environmental Cleaning and Hand Hygiene

The National Nursing Home Quality Improvement Campaign (formerly known as Advancing Excellence in America’s Nursing Homes) provides checklists to assess your current policies, procedures, knowledge, and practices as a first step to identify opportunities to improve. Checklists are provided for early identification/​containment, hand hygiene, and cleaning/​disinfection. Other resources are provided as well on environmental cleaning and hand hygiene.

 Take Action to Prevent and Manage Multidrug-resistant Organisms and C. difficile in the Nursing Home

Watch this recorded webinar presented by Nimalie Stone, MD, MS, a medical officer at the Centers for Disease Control and Prevention (CDC) (1:04:12). In this recorded webinar, Dr. Stone discusses the latest strategies and resources available to effectively reduce the emergence and spread of these dangerous organisms.

Presentation objectives:

• Describe the problem of multidrug-resistant organisms (MDROs) and C. difficile.
• Review the prevention strategies for managing MDROs and C. difficile.
• Outline the actions that caregivers should take to minimize the spread of MDROs and C. difficile.
• Describe national programs developed to support nursing home infection prevention programs in tracking and preventing MDROs and C. difficile.

For the presentation slides: PDF

Environmental Hygiene: Best Practices to Use When Cleaning and Disinfecting Patient Rooms

This video, available in English and Spanish, is intended to compliment the infection prevention education program in healthcare organizations. It was developed by the Oregon Patient Safety Commission and the Oregon Healthcare-Associated Infection Program at the Oregon Health Authority.

    Watch the video in English (8:42).

    Watch the video in Spanish (10:16).