1. Murray, Kathleen DNP, ARNP, NE-BC

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Q Over the last 6 months, my unit had the highest number of reported hospital-acquired Clostridium difficile (C. diff) cases at my hospital. My nurse executive requested that I lead the organization-wide C. diff task force. Where do I begin?

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Your nurse executive clearly understands the seriousness of hospital-acquired infections caused by C. diff. A national prevalence study conducted by the Association for Professionals in Infection Control and Epidemiology found that 13 of every 1,000 inpatients were either infected or colonized with C. diff, which is 6.5 to 20 times higher than previous estimates.1


Before you convene your team, start with hand hygiene education and monitor patient, visitor, and staff adherence. C. diff spores can be transferred from contaminated bedrails, I.V. poles, tables, and other surfaces-virtually anywhere hands can reach. Incorporate The Joint Commission National Patient Safety Goal regarding adherence to either the CDC or World Health Organization hand hygiene guidelines into your initiative.


Implementing and maintaining an effective C. diff prevention program requires a core team that's responsible for developing, executing, and managing the strategy. Although every organization is different, essential members include an infection preventionist, senior leadership, clinical champions (both physicians and nurses), environmental and transport services supervisors, lab support, and quality improvement personnel.


After establishing your team, complete a risk assessment to identify the most significant issues and high-risk areas to help establish goals moving forward. Other items to address in the risk assessment include a review of patient acuity; contact precaution, environmental cleaning, and lab testing protocols; hand hygiene and personal protective equipment adherence; staff education; and antimicrobial stewardship. Next, perform a literature review to learn successful strategies from other facilities.


Key components of a successful C. diff reduction program include:


1. Staff members must be knowledgeable about the signs and symptoms of C. diff so that identification of disease with early treatment can be initiated. The most common symptoms of mild-to-moderate C. diff infection are watery diarrhea three or more times a day for 2 or more days and mild abdominal cramping and tenderness. In severe cases, people tend to become dehydrated and may need hospitalization. Signs and symptoms of severe infection include watery diarrhea 10 to 15 times a day, abdominal cramping and pain (may be severe), fever, blood or pus in the stool, nausea, dehydration, loss of appetite, weight loss, swollen abdomen, kidney failure, and an increased white blood cell count. Additional education includes contact precautions and meticulous hand hygiene because they're key in preventing the spread of C. diff infection.


2. Environmental cleanliness should be a top priority due to the role it plays in the transmission of C. diff. The team should investigate the use of UV light while cleaning all high-touch surfaces with an Environmental Protection Agency approved sporicidal product.


3. Development of an antibiotic stewardship program is a fundamental part of the C. diff reduction plan. Heightened awareness about and monitoring of antibiotic use are essential to reducing excessive antibiotic ordering. A separate subcommittee led by pharmacy staff members reporting to the C. diff task force may speed the progress and productivity of initiatives.


4. Establishing criteria for testing and protocols to reduce the number of unnecessary tests performed is needed to solidify the success of the task force. Based on CDC and Society for Healthcare Epidemiology of America guidelines, only liquid stool conforming to the shape of the collection cup should be tested. Additionally, practitioners should understand that diarrhea alone isn't a reason for testing; it must be correlated clinically with other signs and symptoms, such as fever, abdominal pain, leukocytosis, and/or a change in vital signs. Other testing criteria should include:


* retesting


-If the first test is positive, no retesting during the hospital stay


-If the first test is negative, no retesting within 7 days


* exclusions for testing


-stool that doesn't conform to the shape of the container


-no retest for cure


-patients should be off laxatives 48 hours before testing


-patients on tube feeds shouldn't be tested.


5. Finally, it's important that the task force celebrate accomplishments. Acknowledge and reward units who succeed in reducing C. diff rates. Empower physician and unit champions to make positive changes and influence others by performing hand hygiene to remove C. diff spores and complying with contact precautions.





1. Jarvis WR, Schlosser J, Jarvis AA, Chinn RY. National point prevalence of Clostridium difficile in US health care facility inpatients, 2008. Am J Infect Control. 2009;37(4):263-270. [Context Link]