Preventing the spread of C-diff

Anastasia Gordea, Tony Leon, Linda Phan

Bon Secours Memorial College of Nursing
Description of Problem Fishbone Categories Solution

C-diff infections spreading among patients

because staff and patients are not performing Smart art • Nurses
Solution: Educate patients and reminding staff during
proper hand hygiene. People • Doctors hourly rounding the importance of proper hand
• Patients hygiene. The nurse can remind the patients “Don’t
forget to wash your hands before and after eating”
during hourly rounding.

Analysis: When patients and staff are not educated

Process
Root Cause
Root cause: Staff not educating patients on the importance of
hand hygiene in preventing the spread of C-diff and not
accommodating unique patient needs (education, accessibility)
when it comes to proper hand hygiene.
Equipment
Analysis: there are many factors:
5 Why’s
1.C-diff is a spore bacteria requiring multiple factors to control
(bundle approach) and therefore there is a increased
opportunity for non-compliance by staff and patients.
2.C-diff is resistance to alcohol based hand sanitizers and
surface cleanser.
Regulation
3.Staff and patients not using proper hand hygiene
4.Patients unable of the importance of hand hygiene in reducing
spread of C-diff, or not afforded the opportunity to perform
proper hand hygiene
5.Staff not educating patients on the importance of hand
hygiene in preventing the spread of C-diff and not
accommodating unique patient needs (education, accessibility)
Management
when it comes to proper hand hygiene.
Environment
• Not following proper technique
• Using hand sanitizer instead of soap and water
• Proper donning and doffing of PPE
• Dynamap
• Personal Protective Equipment
• Sink handles
• Compliance
• Educate the effectiveness of hand hygiene
• Must wash hand for 15 seconds or more if
hands are visibly soil
• Education program of proper hand hygiene and
PPE use
• Encouragement and Incentives for proper
behavior
• Reinforcement and frequent re-visiting the issue
• Availability of sinks
• Not enough contact carts
• Hand soap are not refilled properly
enough on the importance of proper hand hygiene, the
spread of infections such as C-diff continues. Patients
who are educated about C-diff infections and how it is
spread can learn to help stop the spread by washing
their hand with soap and water thoroughly. Staff are
educated on the importance of proper hand hygiene
but compliance is low so during hourly rounding, it is
important to remind each other to prevent the spread
of infection by asking each other to wash their hands
often.
References
Haverstick, S. (2017). Patient’s Hand Washing and Reducing Hospital-
Acquired Infection. Critical Care Nurse, 37(3). e1-e8.
doi:10.4037- ccn2017694
Headly, C.M. (2012). Deadly Diarrhea: Clostridium Difficile Infection.
Nephrology Nursing Journal, 39(6), 459-468. Retrieved from
http://search.ebscohost.com/login.aspx?direct=tue&AuthType=ip,at
hens&db= ccm&AN =104404144&site=eds-live&scope=site
Pokrywka, M., Feigel, J., Douglass, B., Crossberger, S., Hensler, A., &
Weber, D. (2014). A Bundle Strategy including Patient Hand
Hygiene to Decrease Clostridium Difficile Infections. MEDSURG
Nursing, 23(3), 145-164. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,at
hens&db= ccm&AN =107863330&site =eds-live&scope=site
 References
• Haverstick, S. (2017). Patient’s Hand Washing and Reducing Hospital-Acquired Infection. Critical Care Nurse,

37(3). e1-e8. doi:10.4037-ccn2017694

• Headly, C.M. (2012). Deadly Diarrhea: Clostridium Difficile Infection. Nephrology Nursing Journal, 39(6), 459-

468. Retrieved from

http://search.ebscohost.com/login.aspx?direct=tue&AuthType=ip,athens&db=ccm&AN=104404144&site

=eds-live&scope=site

• Pokrywka, M., Feigel, J., Douglass, B., Crossberger, S., Hensler, A., & Weber, D. (2014). A Bundle Strategy

including Patient Hand Hygiene to Decrease Clostridium Difficile Infections. MEDSURG Nursing, 23(3),

145-164. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=ccm&AN=107863330&site

=eds-live&scope=site