Management of Increased Incidence of Clostridium Difficile Associated Diarrhea in a 90 Bed VA Nursing Home

BACKGROUND/OBJECTIVES: Incidence of Clostridium difficile associated diarrhea (CDAD) increased in a 90 bed nursing home from 1 per 100 patients(3/277) in the first quarter to 2.4 per 100 patients(6/222) in the second quarter FY04. Immediate actions included (1) Reinforcing staff hand washing with soap and water rather than waterless 62.5% ethyl alcohol hand rub for patients with undiagnosed diarrhea, (2) Changing hospital disinfectant to sodium hypochlorite solution, (3) Placing patients with undiagnosed diarrhea empirically in Contact Precautions, and (4) Increasing frequency of laboratory performance of C. difficile toxins from 3 to 7 times weekly. Rates continued to increase in the 3rd QTR FY04 to 3.4 per 100 cases (7/233). In response, leadership appointed a Root Cause Analysis (RCA) team to analyze the problem with the objective to reduce and control the incidence of CDAD. METHODS: The RCA composed of infection control, housekeeping, nursing, medicine, pharmacy, and supply evaluated the outbreak. Recommendations included: (1) Development of CDAD medical treatment algorithm, (2) Simplification of Contact Precaution signs highlighting importance of hand washing. (3) Extensive C. difficile education for all healthcare professionals, (5) Replacement of isolation carts with Personal Protective Equipment (PPE) cabinets to improve PPE availability, and (6) Improved tracking of CDAD patients transferred in the facility to ensure continuation of precautions. Cost analysis was conducted for CDAD cases vs. non CDAD cases. Fisherʹs exact was applied to determine association of incidence before and after actions. RESULTS: Recommendations were implemented in the 4th QTR FY04. Cases peaked at 4.4 per 100 patients (10/226). (p < .02) During FY05, incidence declined from 4.4 to 2 per 100 patients (17/825). (p < .05) In the 1st QTR FY06, the incidence rate was 0 per 100 patients. (p < .01) Cost savings have been substantial. Pharmacy costs were $30,000 higher and costs of bed days of care were $125,000 higher in CDAD patients than in non-CDAD patients for a total increased cost of $155, 000 per CDAD patient. Costs for CDAD patients in FY05 decreased $1,395,000 over that in FY04. (9 excess CDAD patients in FY04 above 17 in FY05 multiplied by $155,000). CONCLUSIONS: Management and education significantly impacted CDAD occurrence as evidenced by the decrease and control of incidence. Significant cost savings at an estimated $1,395,000 were realized with CDAD prevention activities.