The aim is to reduce/prevent the increase in the outbreak of Clostridium difficile through the use of Chlor-Clean that is appropriately prepared, dated and freshly prepared every 24 hours.
Identifying a problem
According to Nora and Cheryl (2010) clostridium difficile is a sickness that is spread through pores and it results in diarrhea. It is unfortunate that most patients who attend the hospital, get tested, and receive treatments to feel better end up with infections. None of the patients who have antibiotics expects that they can get an infection and more so when they admitted to the hospital. However, unto their dismay, this is what often happens, with the antibiotics therapy increases the chances of acquiring a hospital-acquired infection, especially, those that are caused by Clostridium difficile bacterium. Even though the doctors have been trying to control the problem, it is increasingly becoming enormous and difficult to treat.
The Canadian Nosocomial Infection Surveillance Program in their research determined the presence of 4.74 cases of the bacterium in every 1000 patients that were admitted in Canada between January 2007 and April 2007. As in the United States, some of the data shows that the percentage of those that were discharged from the hospital with CDI infection had more than doubled between 2000 and 2003. However, the rate of those that were 65 years and older was higher compared to that of those of between 45 and 64 years of age. The incidence of increase in the bacterium infection was not exclusive to the US alone but also to other countries such as Canada and Europe. The increase has been noted across the population, from pediatric to the adults, even though, the elderly take the lead (Margaret and Paul 2015).
In regards to Barbut, et al. (2007 ), CDI is associated with increased hospitalization time, which consequently leads to an increase in the costs that are incurred, morbidity and mortality among the adult patients. The patients that were experiencing CDAD were likely to be discharged to long-term care facilities. That implies that the patients with CDAD are more likely to have a longer bed rest. A long bed rest has its disadvantages and especially to the elderly as it brings about disorientation, delirium, psychosocial dysfunction, functional decline, psychical deconditioning, and disruption in social support (Margaret and Paul 2015). It equally leads to muscle support, up to 5 percent on a daily basis, which results in the lower limbs being affected. To prevent the happening of the recurrence of the CDAD, that is something that falls under geriatric practice.
To ensure that the CDI is controlled from happening in the hospitals, there are generally determined strategies that have to be practiced. Literature points on the importance of abiding by antimicrobial usage restriction and stewardship guidelines. The initial strategy would be the avoidance of using electronic thermometers whose handles become contaminated with the C difficile. Secondly, when taking care of the patient it is essential to ensure that one does use dedicated care items and equipment and if they have by any means have to be shared, it is vital to ensure that they are cleaned and disinfected. Thirdly, when contacting a CDAD patient, it is important to take precautionary measures such as the use of gloves (Mehdi, et al. 2014). Fourthly, these patients with CDAD ought to be placed in lavatories and private rooms as a way of isolation to avoid its spread. Fifthly, hygiene consideration is primary, which includes washing of hands using soap and water. Sixthly, the rooms and environment ought to be decontaminated especially were CDAD patients are available. Lastly, it is primary to educate the healthcare personnel so that they may easily identify the CDAD, features, transmission, and epidemiology.
However, after the hospital has taken several measures as a highlight on the above section, there has been a continuous increase of the CDI cases. It is expected that with an increase in the measures of preventing the CDI and CDAD from being transmitted that the cases decrease, but, in this scenario, they have been on the rise. That implies that there is a problem that needs to be identified within the hospital, addressed so that they is a positive change, which implies a decrease in the number of cases that emanate from the infection.
In the process of identifying which practice may not have been well carried out by infection prevention and control team carrying out Medial wards and period of increased surveillance audit (PISA), they realised that what needed improvement was the preparation, storage and documentation of Chlor-clean a disinfectant used for the decontamination of equipments that had been infected and used commodes.
A chlor-clean tablet is dissolved in water to give a solution that can be used to clean and disinfect equipment and commodes. It saves time as it does away with the need to do cleaning and disinfecting as two different activities for it does them all two in one at once. It is used in the cleaning of commodes and clinical equipment that have been used by patients who have CDI. Also, the chlor-clean is also used in the cleaning of rooms, bed spaces, toilets and bathrooms all of which have been used by CDI patients. Notable is that once the solution has been made, it is not stable for a long time, less than 24 hours. Prior to the audit, the cleaning and disinfection would adopt a solution that had been made more than 24 hours earlier and this may have been one of the causes of the spread of the infection as the solution at that time may have been less effective (Barbut, et al. 2007 ).
Examining current practice
This is about the situation as is in the hospital, the number of CDI cases, the number of CDAD cases, the percentage increase of the cases, and how cleaning and disinfection of the equipment and commodes take place in the hospital before the audit (Margaret and Paul 2015). To begin with is that the staffs that were entitled to cleaning and disinfection had a poor trend in that they would use detergents instead of the Chlor-clean in the cases that it was unavailable. The unavailability of the chlor-clean was as a result of lack of a schedule on whom and when it is supposed to be made. The solution would only be prepared by a staff or volunteer at a convenient time. That implies, if there is no one who finds a convenient time it is likely that all the staff would do is clean the equipment and commodes and fail to disinfect them. Disinfecting of equipment and commodes is vital as it failed to carry it out can result to spread if CDI (Andrew 2016 ). So, the lack of decontamination of these equipment using the chlor-clean is the likely reason as to why the rates of the infection are increasing. It is the identification of this problem led to the development of this process of mapping and a planned programme of activities that can result in an improvement in patient care.
The mapping processes
Process mapping is a tool that is used in the improvement of quality and it is adopted in many industries and especially in the NHS. NHS in 2005, in its efforts to realize improve quality in its service delivery to the patients through its Modernisation Agency it published an Improvement Leader’s guide highlighting process mapping, analysis, and redesign. The primary goal of the publication was to add process mapping to the toolkit for leadership improvements. It is vital to know that whenever a process is determined to require review, process mapping exercise then becomes vital in the identification of process gaps and barriers that deter proper function (Phillips et al, 2013). It is also pivotal as it forms part of a wider movement of Lean thinking in healthcare that is focused at efficiency improvement (Burgess et al, 2013). However, the effectiveness of process mapping is derived from the presence of a stakeholder representative. The stakeholders who were part of the process are; Divisional director of nursing, Matrons (medical and Gastro unit), Sisters from both wards, Cleaning supervisors, Staff nurses (including agency and bank staff), Domestic staff and supervisors, Healthcare assistants, Student nurses, A senior Infection prevention and control nurse and Infection prevention and control Link nurses of both wards.
The PISA report that emerged out of the problem identification stage due to a concern in the increased number of DCI despite several strategies employed to ensure that it had decreased was sent to the department head of both units and arrangements were made regarding informal discussions with the matron and ward sisters and cleaning supervisors of the two wards. The aim of starting the process was to ensure that improvements were determined with the aim of positively impacting on patients care. In this regard, it targeted the identification of a system by which chlor-clean is properly prepared, stored, documented and commodes and equipment that have been infected are disinfected with appropriate disinfectant agents that are prepared based on a recommendation. Consequently, after realizing the importance and the urgency of addressing the situation, the matrons agreed to the proposal of organizing for a meeting on a convenient day, time and as at a suitable location for the mapping endeavor. The Divisional Director of Nursing (DDNG) did assist in the identification of a suitable location and despite him not attending, he had promised his support towards the course (Nora and Cheryl 2010).
After making the necessary consultations then, the time for the meeting was agreed upon at 12:30 pm at the place where the staffs conduct their daily huddle. In that regard, the staff day room was identified as the most suitable for the process. It was preferable as it was large makes it spacious for the activity and it had the necessary writing materials. In addition, to ensure that the process was smooth and successful, in achieving the goal for which it had been created then the infection control nurses issued snacks and free pens from a representative. Other requirements that were necessary for the success of the process include tapes, sticky pads, papers, and flip board look for a diagram. Each of the units involved had to send a delegate from each of the staff group. It was unfortunate that the DDNG did not attend the session as they argued that those present were the most suitable persons for the exercise and not him. That implies that the process lacked the involvement of a senior leader who would be important in effecting the necessary change in the hospital to ensure that the CDI cases reduced substantially. However, a sample mapping to follow in rectifying the situation was developed (NHS 2016).
The map that was prepared during the mapping process was then kept in a secure room so that those who never took part in the process like the DDNG would view and make comments. As all stakeholders are primary to the process, a photograph of the map was taken and sends to them electronically. In the process of mapping, there were certain problems that were realized and actions to rectify them would be undertaken through an action plan.
The first problem that was identified is that more than 90 percent of the staff never had the training in the preparation and use of the disinfectant. That probably explains the reason that made them use detergents in washing infected equipment and commodes instead of preparing disinfectant to ensure that they were disinfected not just cleaned. Again, the use of the detergents may not solely be based on the lack of education on how to prepare the disinfectant as some would still use the chlor-clean in its presence because they never knew the difference between the two. In addition, the chlor-clean tabs were hidden in safe locations and obtaining the keys to prepare a solution would take the time that would demoralize those who wanted to engage in the process, hence, making a preference of detergents. Besides, as mentioned, for the chlor-clean to be effective, it has to be fresh at its time of use, implying, it should be used within less than 24 hours after it is been prepared as a solution (Mehdi, et al. 2014). However, there has been a problem in that no one has been keen to document time and date correctly. This may be one of the causes that the CDI is spreading as the disinfectant may have been used later 24 hours after the solution had been made making it less effective to prevent the transmission of the bacterium. Lastly, there is an issue with the fact that there is no one is assigned the responsibility of preparation and decontamination, as every staff who is free and willing and prepare it. The generalization that anyone can prepare it can lead to it not being prepared as all staff may assumedly remain engaged at all times and without no time to prepare.
Plan of action
The first point of action is the post-analysis meeting that was held with the with matron and ward sister, domestic and cleaning supervisions and link nurses of both wards. It pointed out to the area of weakness, that the cleaners were using detergents instead of the chlor-clean which does both cleaning and disinfecting of the equipment and the commodes used in the hospital. If this was effective in the identification of the areas of weakness, it is supposed to be a regular endeavor to meet and identify how to make improvements in any area of cleaning and disinfecting that may be of concern.
The second action that needs addressing is the immediate training of staff on the preparation and the use of a disinfectant agent. The use of disinfectant is vital in the cleaning of equipment infected in the hospital as it is the only that can assist in containing and preventing the spread of harmful bacteria. This disinfectant solution is not used to kill bacteria but it is rather used to reduce the bacteria to the minimally acceptable level.
Although chlor-clean is a pH neutral, implying that the staff of a hospital can easily prepare it without being exposed, it still needs to be stored in a safe place as it is labeled “Acute Hazard Warning Label” implying that it can be hazardous if swallowed or near a flame. Therefore, it should then be safely placed in a locker that uses combination key. The combination key can then be given only to those that are mandated to prepare the solution (Margaret and Paul 2015). With the combination key, it does not take long for the staff to open the safe and prepare the solution.
It has been recommended that to avoid the use of the chlor-clean that is not effective because of staying for over 24 hours since it was prepared, it is important that the date that it is prepared and the exact time be documented. Any staff that would then come to the clean equipment that have been infected and the commodes would check at the record to determine when the solution was prepared. They would then be informed if to use it or prepare a new solution. In addition, there was a nomination for decontamination link staff that is the HCA and staff nurse.
Lastly, as regards to the action plan, the infection prevention and control and cleaning the facility manager was tasked with meeting with PDI (manufacturer) to introduce the use of Chlor-Wipe. The chlor-wipe would be a better version of the chlor-clean as it would be used to easily decontaminate surfaces infected by wiping with a substance containing chlor (Daniel and Thomas 2015). It would then cut on time spent on preparing the chlor solution. It would also be better off because any of the staff can use it safely without lots of restrictions while cleaning areas they assigned to.
An audit is supposed to be an ongoing process. An audit by PISA is what brought into light the causes of an increase in the cases of CDI. It would be prudent after including the recommendations made through an action plan to determine if there is any positive change towards improving the condition. In case no improvements are realized, the audit would point to any other possible causes of the trend.
Staffs are the primary asset in a hospital as they are the brains under whose watch all activities happen and are implemented. Their comments, therefore, are important, as they would highlight on if they find the action plan actionable and if it is bearing fruits in its implementation from their opinion, with supporting reasons.
In conclusion, the research highlights on the identification of increased cases of CDI as a result of lack of information of preparation, storage and documentation of chlor-clean, a cleaning and disinfecting agent. It has been found out that most of the hospital staff use detergents in the place of disinfectants because they do not know if there exist any clear differences between them and also because of the lack of knowledge on how to prepare Chlor-clean. In decreasing the level of CDI it has been determined that the use of Chlor-clean is important in the cleaning of infected equipment and commodes (Andrew 2016 ). However, while cleaning them, the chlor-clean used should have been prepared in not more than 24 hours, at its time of use. Finally, as the hospital management was concerned with ensuring that the level of the CDI cases was reduced to the minimum possible levels they introduced Chlor-wipes which are easier to use compared to the chlor-clean which has to be prepared before use. The introduction of the wipes happened after the manager concerned met with the PDI manufacturer to organize on the possibility of supply.
Andrew, Ofosu. “Clostridium difficile infection: a review of current and emerging therapies.” Ann Gastroenterol, 2016 : 145–154.
Barbut, F, et al. “Clinical features of Clostridium difficile-associated infections and molecular characterization of strains: results of a retrospective study, 2000-2004.” Infect Control Hosp Epidemiol, 2007: 131-139.
Daniel, Leffler, and Lamont Thomas. “Clostridium difficile Infection.” The New England Journal of Medicine, 2015.
Margaret, Quinn, and Henneberger Paul. “Cleaning and disinfecting environmental surfaces in healthcare: Toward an integrated framework for infection and occupational illness prevention.” American Journal of Infection Control, 2015: 424-434.
Mehdi, Goudarzi, Sadat Seyedjavadi Sima, Goudarzi Hossein, Mehdizadeh Aghdam Elnaz, and Nazeri Saeed. “Clostridium difficile Infection: Epidemiology, Pathogenesis, Risk Factors, and Therapeutic Options.” Scientifica, 2014: 9.
NHS. Cleaning and Disinfection of Ward-based Equipment. Doncaster: NHS Foundation Trust, 2016.
Nora, MacLeod-Glover, and Sadowski Cheryl. “Efficacy of cleaning products for C difficile: Environmental strategies to reduce the spread of Clostridium difficile–associated diarrhea in geriatric rehabilitation.” Can Fam Physician, 2010: 417–423.
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