Paul Levy: The Nasty Stomach Bug Called C. Diff
Monday, April 02, 2012
A recent article in Medscape presented serious news about C. diff infections:
The bad news is that for most of the country, CDI rates are still at an all-time high and remain strongly associated with exposure to healthcare. According to Emerging Infections Program surveillance, in 2010, 94% of CDIs occurred in patients who had received healthcare as an inpatient, outpatient, or both in the preceding 12 weeks.[1] C difficile infection is a rising cause of death in the most vulnerable patients. From 2000-2007, deaths from CDI increased 400% -- to 14,000 annually, at a cost of more than $1 billion.
Clearly this is something worthy of attention. In contrast, look at this experience of a pregnant friend of mine while she was visiting a patient in a Boston rehabilitation hospital. Three hospital staff members came in and engaged in conversation, all making notice of the pregnancy of the visitor. In the course of the visit, the visitor held the hands of the patient. A fourth staff member came by and said, "You know you should really be wearing gowns, as the patient has an extremely contagious intestinal infection." The visitor left the room, put on robes, and returned.
Later the patient informed the visitors that she had C. diff. No one on the staff told the guests that C. diff is not killed by the Purell sanitizer, that it takes soap and water cleansing. Fortunately, the guest was aware of that precaution.
The Medscape article suggests that we need to do better than this and can. The article notes that in, three state-led programs, 71 hospitals that focused on reducing the rate of C. diff infections succeeded in cutting the rate of infection by 20% in less than two years.
What did they do? It wasn’t complicated, but it required attention to detail. I was struck that an important aspect is that the nurses and doctors need to talk to patients and ask questions. In the article, Dr. Clifford McDonald from the Centers for Disease Control notes:
Obtain a good history from every patient you encounter, whether he or she is admitted to an inpatient facility or is seen in an outpatient setting. Ask every patient about their bowel habits. Many clinicians hesitate to ask those questions, but that is part of early detection -- finding that stoic patient who has had 3 or 4 loose bowel movements that morning but isn't telling anyone. Nurses especially, being the closest to patients, can often evoke that information.
But another part of the plan requires health care facilities to have good communication with each other. Why? Because infected patients often travel between the hospital and a rehab facility or skilled nursing facility. Dr. McDonald explains:
The engagement of leadership at participating hospitals was a key factor, along with the organizational support of state health departments and their patient safety partners. In very large organizations, it takes a concerted effort not just within a facility, but across facilities, to share information and coordinate regional efforts to prevent CDI. For example, the risk for C difficile transmission is high when patients are transferred from one healthcare facility to another -- from hospital to nursing home or rehabilitation facility and back again. If these facilities aren't working together and notifying each other that a patient has, or has had, CDI, then the appropriate precautions aren't taken.
Another part of the story, though, relates to those of us who are visitors in hospitals. Much of the spread of C. diff occurs in the environment outside of hospitals, as we visitors carry it to other settings. Many of us have learned to use the Purell dispensers as we enter a patient’s room. Some us even remember to use them as we leave a patient’s room. But how many of us think to wash our hands with soap and water after visiting a patient? I know that I usually do not. And, then, when I do, I usually do so in a perfunctory way.
Infectious disease doctors will tell you that you need to spend enough time at the sink when you are washing your hands. They suggest that singing “Happy birthday to you” all the way through while scrubbing your hands with soap and water is a good way to make sure you have been at it long enough.
Look, our mom and dad always told us to wash our hands before eating. How much more wise to do so as we leave a hospital room? It is not that difficult and it can help avoid a more serious “difficulty.”
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