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Prevention and Treatment Bundle Reduced Incidence of Clostridium difficile Infection
Abstract & Commentary
By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Dr. Hoffman reports no financial relationship to this field of study.
Synopsis: Use of checklist-themed prevention and treatment bundles reduced the incidence of Clostridium difficile infection by 40% when evaluated over a 21-month observation period.
Source: Abbett SK, et al. Proposed checklist of hospital interventions to decrease the incidence of healthcare-associated Clostridium difficile infection. Infect Control Hosp Epidemiol 2009;30:1062-1069.
The incidence, severity, and costs of clostridium difficile infection (CDI) are increasing, creating a substantial burden for patients and institutions. Guidelines for prevention of CDI are complex and not consistently followed. This study evaluated an intervention designed to reduce the CDI incidence that consisted of two checklists with actions grouped into prevention and treatment bundles. The prevention bundle included actions to be taken by physicians, physician assistants, nurse practitioners, nursing staff, infection control practitioners, and environmental service personnel. Prevention strategies included specific monitoring and control practices, lab notification procedures, and steps to be taken by infection control and housekeeping services aimed at decreasing CDI transmission. The treatment bundle was designed to standardize treatment of CDI based on three categories (mild, moderate, severe). The checklist defined each category using specific criteria and identified recommended medications, consultations, scans, and duration of therapy for each category.
Surveillance data encompassed 1,047,849 patient-days at one institution (Brigham and Women's Hospital in Boston), including 431,264 pre-intervention patient-days and 616,585 post-intervention patient days. The incidence of CDI deceased from an average of 1.10 cases per 1000 patient-days (95% confidence interval [CI], 1.00-1.21) during the pre-intervention period to an average of 0.66 cases per 1000 patient-days (95% CI, 0.60-0.72) during the post-intervention period. This reduction was sustained for 21 months and amounted to a 40% decrease (P < 0.001). Tests sent for possible CDI increased significantly (P < 0.001). There was an increase in medical acuity with no change in mortality.
Findings of this study are notable for several reasons. The intervention resulted in a statistically significant, hospital-wide reduction in the incidence of CDI when evaluated over a 21-month period. The decrease was substantial (40%) and occurred despite an increase in patient acuity. The checklist developed for the project was concise (< 1 page) but comprehensive as it involved multiple levels of providers, e.g., the medical team, bedside nursing staff, infection control, and environmental services. Actions identified in the prevention and treatment bundles were designed to prevent transmission of CDI in an effective and timely manner. Checklist statements were written in an action-oriented format, e.g., "order stool for C. difficile toxin testing" (medical team), "place dedicated stethoscope in patient room" (bedside nurse), "provide daily list of positive test results" (infection control), and "clean the room with a bleach-based agent" (housekeeping). The treatment bundle included recommended medications for each level of severity, suggested actions if there was no clinical improvement, and indications for infectious disease and general surgery consultations.
The checklist did not restrict the use of high-risk antibiotics because this was judged to require a high intensity of resources, making the intervention less cost-effective. This approach contrasts with prevention efforts that seek to employ antibiotic restriction. The intervention did attempt to increase medical team suspicion regarding CDI and resulted in a significant increase in CDI testing. The authors noted that, while testing has inherent costs, there is a cost to be paid in lives lost and money wasted, in decreased documentation and, hence, spread of CDI. The strategy seemed highly effective, judged by the reduction in incidence of CDI at this hospital and ability to sustain this reduction over time.