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PPO 13-367 – HSR Study

PPO 13-367
Barriers and Facilitators for Clostridium difficile Bundle Implementation
Nasia Safdar, MD PhD
William S. Middleton Memorial Veterans Hospital, Madison, WI
Madison, WI
Funding Period: June 2014 - May 2015
C. difficile is the major infectious cause of nosocomial diarrhea, causing as many as 25% of cases of nosocomial diarrhea. C. difficile infection (CDI) is increasing in incidence and severity, affects 500,000 Americans each year, causes 20,000 deaths annually, and imposes a significant financial burden on healthcare institutions - $1.1 billion annually in the U.S. Preventing CDI is essential; thus, the Veterans Affairs Multidrug Resistant Organism (MDRO) Program Office has recently mandated a national bundle for prevention of CDI at VA facilities. The bundle includes appropriate diagnostic testing, optimization of hand hygiene compliance by monitoring, contact isolation for CDI, and environmental cleaning of rooms of patients with CDI. However, it does not address optimum implementation strategies to ensure successful application of these interventions. Nor does it prescribe how these measures may be undertaken. Implementing and adhering to these recommended measures varies considerably across institutions.

We hypothesize that a number of work system barriers may pose challenges to successful acceptance, adoption, and implementation of the CDI bundle in VA facilities. Our objective is to assess work system barriers and facilitators to bundle implementation using a mixed-methods approach. We will undertake direct observations of practices relevant to CDI prevention at our site and conduct semi-structured interviews/focus groups of healthcare workers (HCWs) and case vignettes.

We will use the innovative Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety. This model, as well as general literature on guideline implementation, will guide interview/focus group questions. Participants will include nurses, physicians, environmental services and leadership. We will conduct direct observations of HCWs based on the SEIPS model. We will observe patient rooms, individuals, tasks, and organization to better understand the overall work system that surrounds the process of care for CDI patients at our site and develop case vignettes for providers.

We have completed all the goals of this proposal. Key findings include;
- An underrecognized role for environmental services staff in C diff prevention
- There are many differences between nurses and physicians in how diagnostic testing to C diff is perceived
- Systems issues related to C diff stem from work load problems with PPE requirement.

This is the first research study to systematically examine barriers and facilitators of implementation of a prevention bundle for CDI, which is a major HAI in Veterans. Our project is innovative in that it will employ the SEIPS framework to undertake a complete work systems analysis for CDI prevention; use a number of complementary approaches to data collection; and consider not just HCWs involved in direct patient care, but also ancillary staff who are critical to successful CDI prevention. Our study methods and approach may be widely used not just for CDI but also other HAIs, and will add to the fields of patient safety and infection control.
We have demonstrated key systems barriers that impede compliance with C diff prevention. Future interventions may use these findings to preemptively address these barriers for implementation to be successful.

External Links for this Project

NIH Reporter

Grant Number: I21HX001490-01

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None at this time.

DRA: Health Systems, Infectious Diseases
DRE: Pathology, Prevention
Keywords: none
MeSH Terms: none

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