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BACKGROUND: Hospitals are required to report CDI and hand hygiene data in Illinois whereas SNF are not. CDI rates more than doubled in the past decade (based on discharge data). CDI moves with patients/residents across healthcare settings. Concerns in both settings include inappropriate antimicrobial use, compliance with handwashing, and unsupervised environmental cleaning. SNF experience unique challenges implementing CDI prevention practices primarily because of the home-like surroundings and insufficient setting-specific resources. Also, a permissive atmosphere, partly in response to pressure from families, allows unnecessary hospitalizations, variances in PPE use, and hierarchical interactions. IDPH implemented a prevention collaborative addressing these issues. Goals included reduction of CDI rates and identifying CDI prevention strategies specific to SNF.
METHODS: Sixteen facilities – 4 hospitals and 12 SNF with which they regularly share patients/residents – were recruited; commitment from both clinical and senior leaders was required. A modified ethnographic approach was used to conduct initial assessments of each facility. An immediately-identified risk among SNF was a tolerance for obvious breaches in recommended CDI practices and lack of direct communication between nurses and physicians. Based on initial assessment findings, the scope was enhanced to address culture of safety basics and process surveillance (hand hygiene; gowning and gloving; and environmental cleaning). Interventions focused on: standardizing CDI prevention practices and agreeing upon expected behaviors; educating about appropriate use of antibiotics, CDI transmission, and how to interact with individuals who resist adherence to infection prevention practices; and hard-wiring oversight. Six months of retrospective data plus one year of real-time monthly data were collected. Hospitals reported denominator data and CDI events using the NHSN portal. Denominator data and CDI events were submitted by SNF utilizing spreadsheets developed by IDPH. All facilities submitted process data utilizing spreadsheets developed by IDPH.
RESULTS: Within 60 days, 82% of SNF made substantial changes: implementing direct communication and single-standard accountability, establishing cross-functional teams, and creating work ethos which supported enforcement of protocols based on medical necessity. The ‘new normal’ – parity, transparency, consistency – was sustained. A framework encompassing CDI-related data in SNF and evaluating practices across care settings has been established.
CONCLUSIONS: Current hospital CDI tactics cannot be easily modified for use in SNF. Unlike other healthcare associated infections, reducing CDI relies on compliance with protocols by everyone entering a facility. Successful elements for SNF begin with culture of safety basics before infection prevention education and performance improvement planning – touchstones untried in SNF.