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BACKGROUND: The Connecticut Department of Public Health (CT DPH) implemented a pilot Clostridium difficile infection (CDI) Prevention Collaborative in Long Term Care Facilities (LTCFs) for six months in 2013, using Quality Improvement (QI) methods and tools. The key outcome measure was to decrease LTCF-attributable CDI 5% from baseline. A wide range of public health and health care stakeholders were involved, including the state health department, hospital association, Quality Improvement Organization, for- and non-profit LTCF associations, LTC directors of nursing, and the state multidisciplinary group. The Public Health Foundation and CDC supported the pilot , by supplying a nationally recognized health care and public health QI coach.
METHODS: A survey with the CDC LTCF healthcare infrastructure tool generated planning data. Registering facilities supplied self-reported baseline CDI data, and outcome data for the latter half of the six month project using NHSN definitions (not validated). Participants also filed monthly reports of time expended to assess sustainability. Collaborative activities included an opening orientation, training, and closing evaluation plenary for facility champions, monthly calls, and on site circuit rider visits by the facilitators to observe, document, and assist QI activities in each facility. Process methods/tools included AIM statements, Plan-Do-Check-Act cycles, brainstorming, multi-voting technique, flow charting, and cause-effect diagrams.
RESULTS: Of the 240 LTCs in the state, 161 responded to the infrastructure assessment survey. CDI was cited as the most challenging HAI (30%). Other HAIs of concern included lower-respiratory tract infections, non-catheter-associated UTIs, pneumonia. The leading infection control challenge was Isolation/MDROs (21%). Other challenges included cohorting, resident cooperation, transfer data, and screening. The collaborative met its ambitious retention and recruitment objective of 25 facilities. The baseline CDI facility onset incident rate was 0.94 per 10,000 pt days; the follow-up rate days was 0.91 per 10,000 pt. days, a three percent decrease. Monthly self-reported time expenditure was 9.1- 11.5 staff hours per facility per month. Data collection was only 12% of the time expended on the collaborative.
CONCLUSIONS: The project demonstrated the tremendous interest and commitment of LTCF staff and their willingness to engage with the public health community to the extent their meagre resources permit. It also demonstrated their willingness to use QI tools if onsite technical assistance was available. Challenges in data collection demonstrated the need for widespread use of NHSN in LTCFs to ensure consistent and comparable data. Plans for the coming year of the collaborative include enrolling 1/3 of participants in NHSN.