Special Edition on Infection Prevention & Control | Page 35

for transmission and infection of patients. However, in practice,
cleaning and disinfection practices vary widely, with studies that
indicating only 50 percent of surfaces are regularly cleaned.
In addition, high-use areas, such as bedside commodes and
in-room sinks, are regularly contaminated and are frequently
not cleaned or disinfected. More recently, increased risk for
acquisition of C difficile has been associated with treatment of
the prior occupant of the room with antibiotics. Therefore, the
national team recommended partnering with environmental
services to ensure that cleaning and disinfection processes
were clearly defined and targeted high-touch surfaces (such
as over-bed tables, bedrails, chairs, sinks, and commodes),
patient-care equipment that directly touches patients (such as
thermometers, stethoscopes, and blood pressure cuffs), and
surfaces touched by health care workers (such as doorknobs,
intravenous infusion pumps, and computers). Furthermore,
these efforts need to be supported with routine competency-based
training, audit, and feedback.
Tier 1, Intervention 6: Monitoring of CDI Rates
and Feedback: Developing and encouraging a culture of
continuous improvement is important for all HAI prevention
efforts. One of the first steps in this process is gathering and
sharing performance data. These data can help institutions
focus enhanced interventions in areas with high incidence of
CDI. Rates of CDI, specific high-risk antibiotic use, adherence
to contact precaution protocols, and HH compliance all play
a role in CDI prevention and can vary widely across different
units in the same hospital. Monitoring these data and providing
them to frontline providers further supports the other tier 1
interventions and makes them more effective.
Tier 2 Practices
Tier 2, Intervention 1: Guide to Patient Safety and
Targeted Assessment for Prevention Strategy: The first
tier 2 intervention is the CDI guide to patient safety (GPS),
a concise, self-administered troubleshooting tool that seeks
to aid infection prevention teams in understanding what
elements may be lacking in their effort to reduce CDI. It consists
of 11 yes/no questions and is modeled after the validated
Catheter-Associated Urinary Tract Infection GPS. The specific
CDI GPS questions are published elsewhere. The CDI GPS is
designed to highlight gaps in current CDI prevention practice
such that specific strategies and resources to overcome barriers
and challenges can be implemented. The CDI GPS provides
tailored resources to help overcome barriers. For example, if an
institution answers that its laboratory does not reject formed
stools submitted for CDI testing, links to best practices in this
topic are provided. The national team emphasized that the CDI
GPS was to be performed before implementing other tier 2
CDI prevention strategies. The team also highlighted the CDC’s
Targeted Assessment for Prevention (TAP) strategy as another
self-assessment tool aimed at helping facilities identify and
address gaps in HAI prevention efforts. The CDI TAP strategy
has five components: running TAP reports based on National
Healthcare Safety Network (NHSN) data, targeting specific
units on the basis of those reports, communicating TAP report
data to engage leadership and clinicians, assessing the gaps in
infection prevention with TAP assessment, and implementing
the appropriate infection prevention strategies with advice
from TAP guides and resources.
Tier 2, Intervention 2: Enhanced Practices: Should CDI
rates remain high despite optimal implementation of tier 1
interventions and completion of the GPS and TAP strategy,
the next step recommended was implementation of expanded
contact precautions. Specifically, sites were recommended to
initiate contact precautions as soon as C difficile tests were
ordered (for symptomatic patients) and to continue these
precautions until discharge as opposed to stopping them
after resolution of diarrhea. Prolonging contact precautions
is resource-intense but can help to prevent CDI spread by
expanding the window of protection. Even after resolution of
diarrheal symptoms, patients with CDI often continue to be
asymptomatic C difficile carriers and can lead to environmental
contamination. Cultures of acute care environments of asymptomatic
carriers have showed a lower rate of environmental
contamination than patients with active
diarrhea (29 percent vs. 44 percent).
However, environmental contamination
by asymptomatic carriers does occur.
Currently, the risk for transmission
from asymptomatic contamination
remains controversial. In one study of
35 asymptomatic carriers, high rates of
environmental contamination (59 percent)
and skin contamination (61 percent)
were observed, and this contamination
was easily transmitted to investigators’
hands. In addition, other factors (such as
stool incontinence) probably play a role in
rates of contamination and are not well
studied. Nevertheless, given the context
of elevated rates despite tier 1 steps,
expanded protection was felt appropriate
and implemented as a first tier 2 step. The
next tier 2 step focused on intensifying
adherence to environmental cleaning
and disinfection. Potential strategies for
this step include the use of fluorescent
markers to ensure that high-contact areas
are effectively cleaned, and the use of
Environmental Protection Agency–approved sporicidal or notouch
disinfectant, such as ultraviolet germicidal irradiation. To
further support this practice, audit checklists, team rounding,
and routine partnering with environmental services personnel
to understand challenges and barriers were encouraged. Finally,
real-time feedback on hand hygiene adherence, development
of frontline physician and nurse champions, targeted competency-based
training for healthcare workers, and inclusion of
patients in HH education were recommended.
Getting to Zero
In January 2008,
the Association for
Professionals in
Infection Control
and Prevention
(APIC) launched its
“Targeting Zero”
campaign which
was designed
to “accelerate
both learning and
the delivery of
practical tools
for infection
prevention
professionals.
In the early-to-mid-2000s, a getting-to-zero campaign set
off debate in the infection prevention and control community
regarding how realistic attaining a zero-infection rate truly was.
In January 2008, the Association for Professionals in Infection
Control and Prevention (APIC) launched its “Targeting Zero”
campaign which was designed to “accelerate both learning
and the delivery of practical tools for infection prevention
professionals,” according to then-APIC president Kathy L.
Warye. At the time, Warye said the program underscored
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