973. Breaking Down the Bundle: Using Quality Improvement Science to Control  C difficile Transmission in a Community Hospital
Session: Poster Abstract Session: Clostridium difficile Infections: Treatment and Prevention
Friday, October 9, 2015
Room: Poster Hall
  • IDSA 2015 Poster.jpg (140.4 kB)
  • Background:

    In 2012, the nosocomial C difficile Infection (CDI) rate at North Shore Medical Center, Massachusetts was significantly higher than other regional community hospitals.  C difficile is linked to 29,000 deaths in the U.S. each year at an excess cost of between $15,000 - $35,000 per case (CDC, 2015).  The hospital environment may serve as a reservoir of infection where both patients’ & caregivers’ hands are easily contaminated.  In addition, unnecessary & inappropriate antibiotic use may trigger the disease.  With constrained resources hospitals need to know where to focus their improvement efforts in order to get results.  Objective:  By systematically implementing & measuring the impact of a series of Quality Improvement interventions to reduce C difficile transmission  in our hospital, we wished  to determine: 1)  the overall impact, and 2) the contribution of each component of the bundle.


    Quasi experimental study design implementing staggered interventions.  Interventions were implemented sequentially at 3-12 month intervals; no other process changes were permitted during these intervals.  Time Series methodology using ANOVA & Poisson tests for statistical significance.

                            Fall 2013 Daily & Terminal Bleach Cleaning of Patient Rooms

    Winter 2013 Soap & Water Hand Washing Campaign;  Installation of Accessible sinks

    Spring 2014 Restricting Fluoroquinolones/Clindamycin; Prospective Approval

    Spring 2015: Enhanced Environmental Disinfection


    In our 375- bed community hospital, we achieved a 28% Reduction in Hospital-acquired C difficile infections, from 1.22 to 0.917 cases/1000 Pt Days over 21 months of followup.  12% of the total decline was attributable to Enhanced Cleaning & Hand Washing; additional 16% decline occurred after the institution of Antibiotic Restrictions.  Fluoroquinolone & Clindamycin Days on Treatment (DOT) fell by 69% & 86% (p< 0.003, p < 0.0001) respectively.  The impact of enhanced environmental disinfection is still being assessed.


    A multipronged approach to reducing C. difficile transmission resulted in a large decline in cases in our community hospital.  The biggest impact occurred with the introduction of  Antibiotic Stewardship requiring prospective approval for high-risk antibiotics.  The full impact of these interventions may not be realized for 36-48 months.

    Barbara Lambl, MD MPH1, Maureen Duram, RN, CPHQ2, Monique Freeley, RPh3, Nathan Kaufman, MD4, William O'neill, BA5, Janice Kurowski, RN5, Marc Rubin, MD6, Paul Seeley, BA7, Frederick Buckley, MD6, Mary Jo Gagnon, BS, MBA8, Wendy Krauss, RN9, Lana Danish, RN10 and Jonelle Oconnor, RN11, (1)Infectious Diseases/Internal Medicine, North Shore Medical Center, Salem, MA, (2)Performance Improvement, NSMC, Salem, MA, (3)Pharmacy, NSMC, Salem, MA, (4)Internal Medicine, Information Technology, NSMC, Salem, MA, (5)Information Technology, NSMC, Salem, MA, (6)Surgery, NSMC, Salem, MA, (7)Environmental Services, NSMC, Salem, MA, (8)Facilities, NSMC, Salem, MA, (9)Infection Prevention, NSMC, Salem, MA, (10)Surgery, North Shore Medical Center, Salem, MA, (11)Medicine, NSMC, Salem, MA


    B. Lambl, None

    M. Duram, None

    M. Freeley, None

    N. Kaufman, None

    W. O'neill, None

    J. Kurowski, None

    M. Rubin, None

    P. Seeley, None

    F. Buckley, None

    M. J. Gagnon, None

    W. Krauss, None

    L. Danish, None

    J. Oconnor, None

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