For Jefferson Healthcare, infection prevention is particularly important. The health system has the oldest patient population in Washington State, making them at high risk for acquiring infection and experiencing complications and higher mortality rates from infections. In 2016 and 2017, the hospital dedicated itself to fully implementing all tiers of the Antimicrobial Stewardship program and saw success in decreasing its overall days of therapy. However, rates of C. diff were increasing at an alarming rate. The Antimicrobial Stewardship Committee established a task force to investigate the issue and provide recommendations for improvement.
The team at Jefferson Healthcare identified over-testing as a contributing cause for the high number of reportable cases. Individuals can be colonized with C. diff without being sick. Therefore, over-testing can lead to detecting and reporting colonized cases that are not reflective of actual infections. The team continued to work together to identify the root causes for over testing – which included:
- Equipment (EHR) – was creating a ‘best practice alert’ that encouraged testing when clinical criteria for C. diff testing was not present
- Systems – there was not a formal training plan regarding C. diff testing and treatment, no policies, and no formal mechanism to review the appropriateness of testing
- Human factors and communication – reliance on technology, workload, interruptions, and distraction led to gaps in communication and teamwork
Strategies for improvement that were tested and implemented included:
- Leadership support – the project was supported by senior leadership and reported to the Executive Quality Council, including Board Members
- Culture of Safety – enhanced teamwork, including the encouragement to question providers about orders for tests
- Policy development to include a new algorithm for testing, designed for providers and lab
- Training based on evidence-based practices and the new testing algorithm
- Creating a stop-the-line moment – when specimens received in lab did not meet the criteria for testing
- Feedback – data collection and reporting
The last reportable case of C. diff was in the fourth quarter of 2017, with six consecutive quarters of no reportable cases of C. diff (through the end of second quarter, 2019).
As a result of Jefferson Healthcare’s work to identify and respond to this opportunity for quality improvement, the hospital was nominated for the WSHA Rural Quality ~ Everyday Extraordinary Award, which recognizes outstanding process improvement by a health system that has resulted in a positive impact on the safety and quality of rural health care. Submissions will once more be accepted starting in 2020. The award is presented annually at the WSHA/AWPHD Rural Hospital Leadership Conference in Chelan. Questions can be directed to Sue Bergmann at SueB@wsha.org. Congratulations to Jefferson Healthcare for its nomination! (Sue Bergmann)