Improving Early Detection of C. difficile Infections

Background: Patients with C. difficile will have liquid, loose, mucous like, or non formed stools. These infections can occur in both the inpatient and community settings and can range from diarrhea to life threatening illness. C. difficile positive stool samples collected within the first three calendar days of hospital admission is considered community acquired. Positive stool samples for C. difficile calendar day 4 or greater are considered hospital acquired. In 2019 and 2020, the P4 surgical intensive care unit (SICU) at Henry Ford Hospital (HFH) experienced high rates of hospital acquired C. difficile infections (CDI). Aim: The purpose of this project was to utilize an electronic health record (EHR) report to conduct early screening for patients to capture CDI during the community acquired timeframe rather than during the hospital acquired timeframe. Methods: Pre-post quasi-experimental retrospective study. Institutional Review Board approval was obtained. Incidence and rate of hospital acquired CDI were tracked from 2019-2022. All community-acquired CDI identified using the stool report were tracked from 2021-2022. Findings: Significant reductions occurred in unit incidence and rates of hospital acquired CDI (Table 2). During the study timeframe, 15 community acquired CDIs were successfully detected within the first 3 calendar days of hospital admission (7 in 2021, 8 in 2022). These infections were detected with the use of the stool report tool and CNS and/or IPC follow up. Without this tool, these CDIs may not have been identified during the community acquired infection timeline. Discussion: October 2021: A Loose Stool Best Practice Alert (BPA) was implemented. This electronic health record BPA alerts nursing staff of potential CDI during the community acquired window. The stool report remains a useful monitoring tool in the event that the Loose Stool BPA is bypassed. The CNS and IPC continue with daily screening of the stool report and follow up with nursing for all potential CDI patients. This quality improvement project is in the process of being expanded to additional units at the hospital. Implications: Delay in CDI detection can cause negative outcomes for patients and can result in inflated hospital acquired rates. Utilizing an electronic report in conjunction with clinical nurse specialist follow up, is an effective method for early screening for C. difficile.https://scholarlycommons.henryford.com/nursresconf2023/1000/thumbnail.jp

UCANP: Urinary Catheter Alleviation Navigation Protocol Quality Improvement Project

Introduction: Catheter associated urinary tract infections (CAUTI) can place significant financial burden on healthcare facilities, decrease quality of care and increase length of stay. Reducing indwelling urinary catheter days reduces the risk of a CAUTI. Current practice after catheter removal includes the reinsertion of the catheter if the patient demonstrates three episodes of urinary retention that requires intermittent urinary catheterization. Intermittent urinary catheterization, when implemented appropriately, has proven to be safe and decreases risk for urinary infection. Background: Several initiatives have been introduced to decrease hospital CAUTI rates, including nursing education on appropriate urine culture collection, use of root cause analysis (RCA) tools to identify problem areas, and nurse driven removal protocols when catheters are no longer indicated. Despite some decreased catheter utilization rates, CAUTIs continued to occur. Data obtained through RCAs revealed a trend of catheter re-insertions due to urinary retention. A nurse driven pathway was developed using bladder scan and straight catheterization protocols with emphasis on not re-inserting catheters. Study Aim: By utilizing an algorithm for monitoring patients after catheter References removal, which includes routine bladder scan assessment and intermittent urinary catheterization if applicable, this study aimed to reduce the incidence of reinsertion of an indwelling catheter. Decreased re-insertion rates contribute to decreased urinary catheter utilization days and decreased risk for CAUTIs. Results: Metrics utilized to determine improvement included indwelling catheter utilization days and CAUTI count. Catheter days is defined as the number of days an indwelling catheter is in place. Each unit was compared to the previous year for the months of September, October, and November. The combined decrease of catheter days for all units was 17%, 23%, and 34% for September, October, and November, respectively. Discussion: Reducing the use of urinary catheters can reduce rates of catheter-associated urinary tract infections and their associated morbidities. Development of one standard protocol, in collaboration with urology provider input, and applying it across a variety of patient populations led to increased utilization of the protocol by the nursing staff. Improvement was also seen in nurses’ awareness and understanding of urinary retention post catheter removal and using bladder scanning and intermittent catheterization appropriately when needed. Due to the initial success of this project, the UCANP initiative is currently being implemented on additional units and will continue until all patient-care areas of the hospital are included.https://scholarlycommons.henryford.com/nursresconf2021/1006/thumbnail.jp

The Impact of an Oral Hygiene Bundle on Hospital Acquired Pneumonias

Background: Hospital acquired infections (HAIs) have a significant impact on patient outcomes with hospital acquired pneumonias (HAPs) accounting for a large part of the cost and care burden. At Henry Ford Hospital, the HAP rate over the last 3 years has increased from 1181 (June 2020) to 1869 (June 2021) to 1078 (June 2022), in large part due to the COVID 19 pandemic. Review of the literature shows that implementation of a nursing protocol with clearly defined steps helped to increase the number of patients receiving oral care and reduced the incidence of hospital acquired pneumonias (Warren, 2019). In addition, oral care as part of the VAP bundle significantly reduced the incidence of pneumonia when compared to oral care alone. Study Purpose: The primary purpose of this evidence based practice project is to evaluate the effectiveness of a standardized oral care regimen on HAPs for all patients in the hospital over a 6 month period following focused education for the nursing staff. Methodology: A site specific oral hygiene protocol was developed and replicated the protocol used by Warren (2019). Nursing staff were educated on the protocol via cornerstone module. Units were encouraged to have unit champions identified to support the implementation of the bundle. HAP rates, LOS and mortality rates were compared 3 months prior to bundle implementation to 3 months post-implementation. Data was abstracted from the EMR and included frequency and type of oral care performed. Data analysis: Data was extracted from the EMR collected in a 3-month period prior to bundle implementation and in a 3-month period post implementation. In each period HAP rates, LOS and mortality rates were computed. The two rates, HAP and mortality were compared using a Chi-squared test. and LOS using a Student’s t-test. Discussion: At Henry Ford Hospital, the HAP rate over the last 3 years has increased significantly, in large part to the COVID 19 pandemic. Research shows that implementation of a nursing oral care protocol with clearly defined steps helps to increase the number of patients receiving oral care and reduces the incidence of hospital acquired pneumonias Data from this project shows that as the number of oral care interventions increased there was a concomitant decrease in VAP. The education intervention resulted in increased adherence to the protocol as well as increase in documentation of care provided. In addition, length of stay decreased while discharge to home remain unchanged. Mortality rate and discharge to SAR both decreased slightly. Clinical Implications: The project is low risk with high benefit, and is a standard of care that all patients receive. This may influence how patients manage their own oral care after discharge. Study Limitations: The impact from Covid-19 is still present in the hospital, and may impact outcomes as related to available resources and manpower. Data retrieval was from the EMR and will only be as good as the data entered. Conclusion: Providing oral care is a simple and minimal cost intervention that can have significant impact on patient outcomes related to HAP. Educating staff on the value of oral care can help improve adherence to oral care protocols.https://scholarlycommons.henryford.com/nursresconf2023/1005/thumbnail.jp