Stop spread of C. difficile? Methods matter, research shows

Increased activity to prevent the spread of Clostridium difficile, which is linked to thousands of deaths annually, is failing to reduce infection rates, which have reached historically high levels.

That's the finding of one recent survey. But another study shows that the person who cleans and disinfects patient rooms and how it is done can make a difference in controlling the deadly bacteria.

According to a recent survey by the Association for Professionals in Infection Control and Epidemiology (APIC), 70 percent of respondents said the hospital in which they work has adopted additional interventions to address the problem of C. difficile infections (CDI).

Yet, only 42 percent witnessed a decline in their CDI rates during that period, while 43 percent did not see a decline, according to APIC's 2013 CDI Pace of Progress survey conducted Jan. 14–28, 2013. Survey results were presented in March at APIC's Clostridium difficile Education and Consensus Conference
in Baltimore.

While cleaning activity has increased, monitoring the results has not kept pace, the survey reported. While 92 percent of respondents have increased emphasis on environmental cleaning and equipment decontamination, 64 percent said they rely on observation instead of more accurate monitoring technologies to determine cleaning effectiveness. Fourteen percent said that nothing was being done to monitor room cleaning.

Because C. diff spores can survive in the environment for many months and are highly resistant to cleaning and disinfection, environmental cleaning and disinfection are critical to prevent the transmission of CDI, APIC says.

But how it's done makes a difference, notes a study published in the May issue of Infection Control and Hospital Epidemiology, the journal for the Society for Healthcare Epidemiology of America. The study describes the importance of establishing a rigorous cleaning and monitoring regime to control C. diff.

The study notes that a dedicated daily cleaning crew who uses a standardized process to clean and disinfect rooms contaminated by C. diff can be more effective than other disinfection interventions.

The cleaning crew used fluorescent markers to monitor cleaning effectiveness, an automated ultraviolet radiation device and bleach wipes to augment disinfection after cleaning. A combination of the dedicated cleaning crew and enhanced methods reduced the presence of C. diff in patient rooms by 89 percent during a 21-month study conducted at the Cleveland Veterans Affairs Medical Center.

There are 337,000 hospitalizations for C. diff annually in the United States and C. diff is linked to about 14,000 deaths, adding at least $1 billion in health care costs, according to the Centers for Disease Control and Prevention.

Jennie Mayfield, clinical epidemiologist, Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, and president-elect, APIC, says science about C. diff's multiple strains and how the pathogen moves among populations remains a mystery.

"I think until we answer some of those basic questions, hospitals are going to continue to do what seems to work in their individual facilities. It becomes a case of my hospital is doing one thing and the hospital next door may do something else to prevent the spread," she says.

Mayfield says that experts suspect that patients may remain colonized with C. diff and continue to shed the bacteria for an undetermined period after symptoms evolve.

"Those persons could be a source of new infection if they're not isolated. So we may need to prolong isolation; we may need to screen people on admission. None of that's happening right now," she says.

Mayfield is encouraged by ongoing research that shows promise for a vaccine that may prevent infection. Persons who are colonized with a nontoxigenic strain of C. diff don't get the toxigenic strain, so it's possible that being colonized protects them from infection. Patients who are admitted or readmitted to the hospital would be vaccinated as a safeguard.

Hospitals increase energy-efficiency, cut emissions with CHP

The Environmental Protection Agency (EPA) recently recognized two New York City hospitals and a power plant serving several Boston health care facilities for utilizing highly efficient and environmentally friendly combined heat and power (CHP) systems.

Energy Star CHP Award winners include Montefiore Medical Center and New York-Presbyterian/Weill Cornell Medical Center, both in New York City. EPA also recognized Medical Area Total Energy Plant (MATEP), which serves several hospital, teaching and research facilities in Boston.

"These institutions are protecting their critical operations from power outages and protecting our climate from harmful carbon pollution with reliable and more efficient CHP systems," says Gina McCarthy, assistant administrator for EPA's Office of Air and Radiation.

CHP systems, also known as cogeneration, capture waste heat from electricity generation, and use the heat to generate steam or hot water for both cooling and heating. A single energy source such as natural gas commonly is used in the system.

MATEP's 46-megawatt CHP system produces steam, chilled water and electricity for the Longwood Medical and Academic Area (LMA). Located in Boston, the 200-acre LMA is home to Boston Children's Hospital, Brigham and Women's Hospital and several other health care facilities.

Two natural gas-fired combustion turbines equipped with heat recovery steam generators power the CHP system, producing up to 360,000 pounds of steam per hour and 24 megawatts of electricity. The steam drives turbines to generate an additional 22 megawatts of electricity and also to heat water for space heating and other uses. Several chillers use part of the steam output to produce chilled water for space cooling.

With an operating efficiency of 75 percent, MATEP's CHP system requires approximately 24 percent less fuel than using electricity from the grid and producing steam with a boiler. The system prevents an estimated 117,500 tons of carbon dioxide emissions annually.
Employing a network of five internal combustion engines and one combustion turbine, Montefiore's CHP system generates up to 11 megawatts of electricity and produces up to 27,000 pounds of steam per hour utilizing otherwise wasted heat. ]

The steam is used to meet more than 95 percent of the medical center's thermal energy demands, including hot water, space heating and cooling.

With an operating efficiency of 69 percent, Montefiore's CHP system requires approximately 26 percent less fuel than using electricity from the grid and producing boiler steam. The system prevents an estimated 17,900 tons of carbon dioxide emissions per year.

Using a natural gas-fired combustion turbine and heat-recovery steam generator, the CHP system at New York-Presbyterian/Weill Cornell Medical Center generates up to 7.5 megawatts of electricity and produces up to 70,000 pounds of steam per hour.

With an operating efficiency of 72 percent, the system requires approximately 27 percent less fuel than using electricity from the grid and producing boiler steam. The system also prevents an estimated 21,500 tons of carbon dioxide emissions from entering the atmosphere per year.

For more information on the program, log on to www.epa.gov/chp.

Atlantic Health earns accolades for security steps

The Atlantic Health System, Morristown, N.J., has developed a rigorous safety program called Red Cell, using undercover agents to test for weaknesses in hospital security. The effort has helped to strengthen Atlantic's protocols, while also earning industry accolades.

Atlantic toughened its security after 9/11 by adding card readers and security cameras. But those measures weren't always effective in preventing unauthorized persons from entering its facilities.

Atlantic Health brought in former law enforcement officers and security experts in 2009 to identify and prevent potential breaches by working undercover to gain unauthorized access to sensitive areas within system facilities.

During these surveys, the undercover, plainclothes agents test locks and access to equipment, as well as the ability of employees to question or challenge individuals as to whether they are authorized to be in a particular area. The intent is to help the health care system's managers tighten security where needed.

"The best way to begin to fortify your security is to identify the potential risks," Alan Robinson, director of protection and security services and emergency management for Atlantic Health System told Health Facilities Management's sister publication Hospitals & Health Networks.

Results of Red Cell have been promising, as Atlantic Health has experienced a noticeable decline in the number of times agents were able to infiltrate hospitals over the past few years — from 22 percent of the attempts in the first year of the program, down to 5 percent last year.

Last month, Atlantic earned one of CSO magazine's inaugural CSO40 Awards, honoring security projects "that demonstrate outstanding business value and thought leadership." The Joint Commission also recognized the Red Cell program last year as an example of security best practices.

U.S. intelligence agencies and others have used Red Cell for decades to obtain insights from persons outside their organizations.

Patients' design input creates better hospitals

More than $600 million in construction projects either recently completed or under way in four states will feature at least nine new health care facilities built by Mercy, St. Louis, by spring 2015.

To make sure Mercy provides the best possible experience for patients, who better to provide input on new facility design than the patients and community being served?

The health system provides opportunities for patient input on a regular basis by establishing local community advisory groups and other ways to communicate suggestions for each construction project, says Beth Kistner, director, customer experience, at Mercy. More importantly, Mercy has enhanced its facilities by incorporating patients' ideas, she adds.

"In the last three years or so, there has been an explicit and intentional attempt to bring our patients directly into our projects so that we're matching up what we're doing with their needs and expectations," she says.

For example, Shan Carter, Spencer, Okla., who has a rare form of multiple sclerosis, served on the advisory group for the new Mercy Rehabilitation Hospital Oklahoma City.

Being wheelchair-bound for the past two years enabled Carter to offer insight into something as simple, yet critical, as the size of bathrooms in the rehab facility. Many bathroom doorways are now 6 inches wider and bathrooms are 5 inches bigger for easier maneuvering in wheelchairs due to his input.

Patient input also resulted in changes to the labor and birth suites at Mercy Hospital St. Louis so there is proximity between the baby's bed and the mother. Other changes included improving the proximity and size of bathrooms, especially to accommodate patients' using an IV pole, and installing high-end shower jets in patient bathrooms.

Thanks to community input, numerous changes were incorporated at the new neonatal intensive care unit (NICU) in Springfield, Mo. Among them were giving parents the ability to stay with their babies in the NICU and providing a room for family members.