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Each hospital had been trying to combat C. difficile on its own, but they were often outwitted by the hardy spore, which is fueled by overuse of antibiotics, spread by hands and able to survive on bed rails, call buttons and doorknobs for as long as five months if not longer and cleaned off.
Plus, it was traveling: Patients in one hospital or nursing home were often discharged and then admitted to another. Dealing with the mess was costing the hospitals an estimated $4 million to $5 million a year.
So they did something rare for competing health-care systems. Four hospitals joined forces to beat back the debilitating bug, forming a C. difficile prevention collaborative. Six nursing homes that share patients with the hospitals and had a huge C. difficile problem of their own then formed a separate alliance.
It paid off: In the 12 months ended in September 2015, rates of C. difficile infections fell 36% from 2011 levels across the hospitals, which initially were in three but are now in two health-care systems: the University of Rochester Medical Center and Rochester Regional Health System.
“It’s not very simple—you have to have a multidisciplinary approach to prevent this infection,” says Ghinwa Dumyati, who leads both the hospital and nursing-home collaboratives as an infectious-disease physician with the Center for Community Health at the University of Rochester Medical Center. “We needed to work together.”
A good cleaning
Hospitals compete intensely for patients, doctors and insurance dollars, but when it comes to safety, they are increasingly collaborating to solve common problems, according to Arjun Srinivasan, an expert at the Centers for Disease Control and Prevention in the prevention of health-care-associated infections. The CDC says working together allows hospitals to more effectively fight infections caused by drug-resistant bacteria and C. difficile because the bugs are intractable and the difficulties each facility faces are similar. Plus, Dr. Srinivasan says, “hospitals share those patients.”
New federal requirements to improve health-care quality, such as public reporting of health-care-associated infections and penalties for readmissions, also are prodding hospitals to collaborate more on safety issues, Dr. Srinivasan and hospital executives say.
C. difficile is the most common pathogen causing health-care-associated infections in U.S. hospitals, according to the CDC. It led to approximately 453,000 infections and 29,000 deaths in the U.S. in 2011, according to a study last year in the New England Journal of Medicine.
Infections occur when someone ingests C. difficile and takes antibiotics that wipe out the good bacteria in their gut. That leaves the C. difficile to flourish in the colon, producing diarrhea that can last for weeks or months. The elderly are particularly at risk of infection because their immune systems may be weak, and they are frequent users of hospitals and nursing homes.
Rochester’s C. difficile-prevention collaborative began in 2011, funded by the health-care
systems involved and a large regional insurer, Excellus BlueCross BlueShield. It grew out of an earlier initiative that Dr. Dumyati had led that sharply reduced bloodstream infections from central lines, or catheters, inserted in the body. This time, the collaborative—Dr. Dumyati, along with doctors, infection preventionists and others from the hospitals—
chose to target C. difficile. “We knew we had a lot of cases,” she says.
First, the collaborative focused on cleaning procedures. The hospitals taught staff to scrub long and hard with bleach wipes to get rid of super-resilient C. difficile in hospital rooms. “Just like if you’re washing a plate, you have to apply pressure to get food off,” says Jeanna Hibbert, who cleans rooms at Strong Memorial Hospital, one of the four participating hospitals.
They also introduced inspections of cleaned rooms, using a tool that checks for even small amounts of contamination. “That was new and extraordinarily helpful,” says Robert Panzer, chief quality officer and associate vice president at Strong Memorial.
Each hospital made changes in its own way, and borrowed ideas from the others. Strong Memorial dedicated a crew to clean the rooms of discharged C. difficile patients after determining that it takes an hour and half—twice as long as normal—to properly clean them, adopting a practice from its sister, Highland Hospital.
After the collaborative laid out a policy for treating less severe forms of pneumonia, Strong Memorial pharmacists changed an electronic order form for antibiotics to prevent physicians treating those infections from prescribing a class of drugs linked to C. difficile infection without special approval, says Dr. Dumyati.
Across town at Rochester General Hospital, staff promoted the new pneumonia policy in a newsletter for doctors. Use of the desired antibiotic, doxycycline, for pneumonia more than tripled in a year; use of the one it replaced fell 48%, the hospital says.
The team at Rochester General also created a poster with new guidelines for diagnosing and treating urinary-tract infections after the collaborative determined that five out of six of its hospital patients treated for them don’t actually have them. Dr. Dumyati adopted it for use in the nursing homes she had started to work with, with a grant from the state.
The new policies have helped Rochester General strengthen an antibiotic stewardship program it adopted a few years ago, in which a team of experts reviews antibiotic prescriptions, says Maryrose Laguio-Vila, the program’s director. “We gain insight into whether what we’re doing is along the right track or can be tweaked in a certain way.”
The collaborative has helped all of the hospitals improve their practices and patient care, says Nayef El-Daher, chief of infectious disease at Unity Hospital. “When we started the project, every one of us had [our] own ideas and protocols,” he says.
The next front
Dr. Dumyati feeds data on C. difficile infection rates and other measures every quarter to each of the hospitals, so that they can see how they’re doing. “The data really drive where we go next,” she says.
Next, she hopes to take the new policies to doctors’ and dentists’ offices. About 35% of all C. difficile infections aren’t linked to stays in hospitals or long-term-care facilities, according to the NEJM study.
“It’s fairly clear that you have to work with the nursing homes and you have to work across the community to make progress,” says Mark Shelly, chief of infectious disease at Highland Hospital. “Otherwise we’ll be pointing across the fence for a long time.”
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