The Effectiveness of a Multidisciplinary Bundle Intervention Compared to a Non-Bundle Approach in Controlling Clostridium Difficile Infection Rates in Hospitalized Patients

Analysis of Survey Results

Rhetoric about the adoption of evidence-based practice (EBP) exceeds the extent it has been implemented. EBP is stated as being central to the mission and philosophy of the organization. However, a major obstacle to the transition to EBP is that most decisions are still made by upper administration. Successful implementation of EBP requires a combined top-down and bottom-up approach. There is a lot of rhetoric about shifting decision-making to the unit level, but it has only been done to a limited extent. This has impeded progress because of all professional groups’ nurses are the most amenable to adopting EBP. This may be because EBP expands the scope and professionalism of nursing practice. In addition, EBP is consistent with the holistic model of care central to the philosophy of nursing. Physicians tend to be more resistant to change although there are many physicians who are open to innovation and eagerly embrace EBP. Advanced practices nurses and physicians who work collaboratively on multidisciplinary teams are some of the biggest champions of EBP.

There are few nurses with Ph.D.’s, although several nurses pursuing advanced degrees are highly interested in carrying out research and applying the results to improving patient care. Many nurses possess the knowledge and skills to act as mentors and change leaders for integrating clinical inquiry into the organization. Teamwork and collaboration both need improvement and nurses, physicians, and other staff members with experience on multidisciplinary teams could make excellent advocates and change leaders.

The organization has devoted a substantial amount of resources to planning and implementing EBP. To some degree, this has been in response to external pressures, which could account for a relative lack of EBP champions among administrators. Organization-wide communication presents a challenge as channels of communication have traditionally been poor. On the other hand, there is relative access to technology and the staff is tech-savvy and eager to improve patients care through more extensive use of technology.

There has not been much change to the extent that EPB has been implemented within the last six months. However, the shift toward EPB may be gaining momentum, as there has been more intensive internal and external pressure for change within the last two months.

Statement of the Problem

Clostridium difficile is the most common cause of antimicrobial drug-associated disease in hospitals and long-term care facilities in the United States (McGlone et al., 2012; Reed, Edris, Eid, & Molitaris, 2009). The full scope of the problem extends beyond the U.S. The World Health Organization (WHO) has declared antimicrobial resistance to be “one of the three greatest threats to human health” (Nowak et al., 2012, p. 1500). Although there is no evidence documenting a direct cause-and-effect between reliance on antibiotics and Clostridium difficile infection (CDI), the association between the two is generally accepted. However, despite growing evidence of inappropriate use of antibiotics, there is minimal evidence that the practice is changing. Therefore, transforming practices within health care organizations requires concerted, organization-wide collaboration, with a sound research base to support the change initiative. Multidisciplinary teamwork and collaboration are essential for combating CDI (Eiland, 2011; Muto et al., 2007; Nowak, Nelson, Breidenbach, Thompson, & Carson, 2012; Palmer et al., 2011).

Significance to Stakeholders

Evidence from the National Hospital Discharge Survey (NHDS) documents that the prevalence of Clostridium difficile has been escalating among patients initially hospitalized for short stays, with patients aged 65 or older and those with compromised immune systems and comorbid conditions being especially vulnerable to infection (McDonald, Owings, & Jernigan, 2006). Clostridium difficile carries substantial human and financial costs. In addition to the financial costs to hospitals and third-party payers, patients can suffer serious complications or death. Lost productivity is a consequence for younger patients and older patients who are still in the workforce. If resistance continues, the infection is likely to spread into communities at even greater cost.

Data from Pennsylvania hospitals from 1995 to 2005 document the tremendous burden of CDI (Reed et al., 2009). During that time frame, the number of hospitalizations due to CDI rose an astounding 173%. Furthermore, patients with CDI spent more than twice as much time hospitalized, had more than twice the financial costs, and had four times the mortality rate as patients without CDI. Due to the speed that CDI can spread throughout the facility if it is not quickly detected and precautions taken immediately, anyone who is hospitalized stands to benefit from an organization-wide, evidence-based nursing approach to controlling CDI. Those who are most at risk by virtue of age and/or health status would have a great benefit in terms of reduced risk of morbidity and mortality.

Using an economic computer simulation, McGlone et al. (2012) estimated the costs of hospital-acquired CDI to hospitals, to third-party payers, and to society. The societal costs included indirect costs such as lost workdays for employed patients and/or their caregiver, lost activities for retired people, and productivity losses from premature death as well as direct medical costs. Translated into annual figures, the financial costs of CDI each year are at least $496 million to hospitals, at least $547 million to third-party payers, and at least $796 million to society. Furthermore, the researchers added that these figures are probably conservative.

Hospitals not only incur financial costs due to CDI, but the associated morbidity and mortality, and certainly public knowledge of an outbreak of infection such as tuberculosis, jeopardize their reputations. The intensive efforts to control an outbreak once it has occurred divert staff resources in organizations that are often short-staffed. The high costs to hospitals and third-party payers had the potential to drive up health care costs for many consumers. The high cost to society implies that policymakers and public health officials should be key stakeholders in initiatives to control CDI along with hospital administrators and staff.

Purpose and Objectives of the Project

The purpose of this research project is to determine the effectiveness of a comprehensive multidisciplinary “bundle” intervention involving enhanced early detection of cases, education, microbial stewardship, and expanded infection control measures in controlling the rates of CDI among hospitalized patients compared to a non-bundle approach. It is hypothesized that after six months, the bundle intervention will prove superior to the non-bundle approach in reducing the incidence of CDI among hospitalized patients.

Gerding, Muto, and Owens (2008) declare that “All hospitals should actively monitor the severity and rate of hospital-acquired CDI as part of their infection control programs so they can determine whether the rate is acceptable and quickly detect any increases in the CDI incidence, CID-associated mortality rate, and colectomy rate” (p. S43). Immediate identification of patients with CDI is requisite for stemming infection so that those patients can be isolated, and treatment began. In addition to the benefits of early intervention for the patient, this decreases further environmental risks.

Hand hygiene is the main tactic for decreasing the prevalence of nosocomial infection (Vonberg et al., 2008). The use of alcohol-based hand sanitizing agents rather than soap and water has been implicated in the spread of CDI. Diligent handwashing with soap and water by all staff members is advised. Sanitizing the patient environment and taking isolation precautions by placing patients with CDI in private rooms or a room with another patient with CDI are recommended to stem further infection. While these strategies have documented effectiveness in controlling infection, a cohesive, comprehensive multidisciplinary intervention has a greater capacity for controlling infection than a fragmented approach that may result in delayed detection and intervention. In addition, multidisciplinary teamwork makes more efficient use of the organization’s human resources.

Literature Review

The literature presented in this review is drawn from PubMed, including Medline, the website of the Centers for Disease Control and Prevention (CD), and the EBSCO databases Academic Search Premier and MasterFILE Premier. The following keywords were utilized either individually or in conjunction: Clostridium difficile, infection, diarrhea, hospitals, patients, nurses, prevention, intervention, antibiotics, evidence-based practices, teamwork, multidisciplinary, education, leadership, and organizational change. The searches were limited to include only sources from 2003 to the present.

A search utilizing the keywords “Clostridium difficile,” “hospital patients,” and “nursing intervention” drew only one source, the research study by Nowak et al. (2012), a multi-disciplinary antimicrobial stewardship program led by pharmacists. Palmer et al. (2011) described a stewardship intervention in detail. Findings show that this type of program is effective in decreasing the incidence of nosocomial infections including Clostridium difficile. Simply using the terms “Clostridium difficile,” “hospitals,” and “patients” generates several hundred articles. However, once the word “intervention” is added to the search, the number decreases substantially, thus highlighting the need for more research in this area. Searching “Clostridium difficile” with either “evidence-based practice” or “organizational change” produced virtually no results, once again, showing the need for more research. The only related meta-analysis focused on the use of probiotics for preventing CDI-associated disease in hospitalized patients (Avadhani & Miley, 2011).

Interventions. Muto et al. (2007) investigated the use of an infection control bundle intervention for dealing with an outbreak of the hypervirulent CDI BI strain at a university hospital. An important element of the program was an education module for both health care professionals and patients. Notably, primary care nurses played a leading role in the intervention. Education and early identification were the cornerstones of the program, which focused on hand hygiene and patient isolation. The program succeeded in reaching its target rate of 5.0 infections in 1,000 hospital discharges and in sustaining this rate. Gerding et al. (2008) recommend using the program described by Muto et al. (2007) as an example of an effective comprehensive strategy for controlling CDI.

Eiland (2011), Nowak et al. (2012), and Palmer et al. (2011) all described multidisciplinary pharmacist-led stewardship interventions for controlling the outbreak of CDI- associated disease. Palmer et al. (2011) presented the program adopted by the Center for Antimicrobial Stewardship and Epidemiology (CASE) at St. Luke’s Episcopal Hospital in Houston, Texas. The CASE team utilized an eight-component strategy to control infection: (1) using real-time data to promote optimal microbial therapy customized to each patient; (2) minimizing excessive utilization of broad-spectrum antibiotics or prolonged therapy; (3) ensuring that the dosage of antimicrobial treatment is based on characteristics specific to the patient, the pathogen, the infection site, and principles of pharmacology; (4) decreasing adverse drug reactions through diligent patient individualization measures; (5) performing ongoing surveillance of antimicrobial resistance patterns, nosocomial infections, and adverse drug incidents, and analyzing all pertinent findings; (6) providing education on microbial stewardship via one-on-one collaboration, committees, and written communication; (7) ensuring that all decisions are based on a synthesis of all relevant data; and (8) conducting research related to antimicrobial use and infectious disease protocols throughout the organization.

All the components of the stewardship program described by Palmer et al. (2011) require multidisciplinary communication and collaboration. However, the last element specifically targets the need for research that extends throughout the organization.

Nowak et al. (2012) conducted an analysis of data on the effectiveness of an antimicrobial stewardship program, examining costs as well as clinical outcomes. The researchers reviewed the charts for 2,186 patients treated for pneumonia and 225 patients who received treatment for intra-abdominal sepsis during the three years prior to the implementation of the program and the three years following its implementation. The findings confirmed that the program resulted in a decline in the overall use of antimicrobial agents and a decline in related costs. Overall, the evidence documented a significant drop in the prevalence of nosocomial infections caused by resistant pathogens. At the same time, the results did not demonstrate changes in the length of hospital stay, survival rate, or hospital readmission for either type of nosocomial infection. There may have been a need for a more comprehensive approach than the strategies under study.

A key implication of the existing research on interventions for reducing the incidence of CDI is that teamwork and collaboration are pivotal to program success. Although individual components may be simple (such as handwashing with soap and water and sanitizing equipment and the environment), it is clear that a collaborative, organization-wide approach is required, with ongoing research to examine the outcomes and determine where improvement is needed.

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References

Avadhani, A., & Miley, H. (2011). Probiotics for prevention of antibiotic-associated diarrhea and Clostridium difficile-associated disease in hospitalized adults—a meta-analysis. Journal of the American Academy of Nurse Practitioners, 23, 269-274. doi:10.1111/j.1745-7599.2011.00617.x

Eiland, H., III. (2011). Activities of a Clostridium difficile infection reduction team. American Journal of Health-System Pharmacy, 68, 1198-1301. doi:10.2146/ajhp100664

Gerding, D. N., Muto, C. A., & Owens, R. C., Jr. (2008). Measures to control and prevent Clostridium difficile infection. Clinical Infectious Diseases, 46(Suppl.1), S43-S49. doi:10.1086/521861

McDonald, L. C., Owings, M., & Jernigan, D. B. (2006). Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerging Infectious Diseases, 12, 409-415. Retrieved from http://www.cdc.gov/eid

McGlone, S. M., Bailey, R. R., Zimmer, S. M., Popovich, M. J., Ufberg, P., Muder, R. R., & Lee, B. Y. (2012). The economic burden of Clostridium difficile. Clinical Microbiology & Infection, 18, 282-289. doi:10.1111/j.1469-0691.2011.03571.x

Muto, C. A., Blank, M. K., Marsh, J. W., Vergis, E. N., O’Leary, M. M., Shutt, K. A., ...Paterson, B. A. (2007). Control of an outbreak of infection with the hypervirulent Clostridium difficule BI strain in a university hospital using a comprehensive “bundle” approach. Clinical Infectious Diseases, 25, 1266-1273. doi:10.1086/522654

Nowak, M. A., Nelson, R. E., Breidenbach, J. L., Thompson, P. A., & Carson, P. J. (2012). Clinical and economic outcomes of a prospective antimicrobial stewardship program. American Journal of Health-System Pharmacy, 69, 1500-1508. doi:10.2146/ajhp10603

Palmer, H. R., Weston, J., Gentry, L., Salazar, M., Putney, K., Frost, C., ...Garey, K. (2011). Improving patient care through implementation of an antimicrobial stewardship program. American Journal of Health-System Pharmacy, 68, 2180-2174. doi:10.2146/ajhp10063

Reed, J. F., III, Edris, B. A., Eid, S., & Molitoris, A. (2009). Clostridium difficile: The new epidemic. Internet Journal of Infectious Diseases, 7(1). Retrieved from http://ispub.com/IJID/7/1/10115

Vonberg, R.-P., Kuiper, E. J., Wilcox, M. H., Barbut, F., Tull, P., Gastmeier, P., ...Wiuff, C. (2008). Infection control measures to limit the spread of Clostridium difficile. Clinical Microbiology & Infection, 14(Suppl. 5), 2-20. doi:10.1111/j.1469-0691.2008.01992.x

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