Background
Methods
Data collection
Participants
Data analysis
Criteria for Clostridium difficile knowledge | Points |
---|---|
Signs and symptoms (diarrhoea) | 1 |
States characteristics of bacteria (any mention of: microbiology, virulence mechanism, disruption of normal flora, opportunistic) | 1 |
Soap and water needed to clean hands, not just alcohol | 1 |
Treatment options (any mention of: metronidazole, oral vancomycin, fecal transplant, contraindication with loperamide) | 1 |
Contact isolation needed (or contagious) | 1 |
Risk factors (immunocompromised, antibiotic use, proton pump inhibitors) | 1 |
Diagnosis (stool sample, testing methods [PCR/toxins]) | 1 |
Total points | = |
No knowledge = 0–1a Limited knowledge = 2–3 Moderate knowledge = 4–5 Advanced knowledge = 6–7 |
Results
Healthcare Provider Occupation | Participants | Interviews |
---|---|---|
Nurse | ||
Operational managers or Assistant manager | 4 | 4 |
Registered nurse or unspecified nurse | 4 | 4 |
Infection Prevention and Control Nurse | 2 | 2 |
Nurse Training Clinical Program Coordinator | 1 | 1 |
Ward Nurses Focus Group Interview | 7 | 1 |
Subtotal: | 18 | 12 |
Pharmacist | ||
Pharmacist | 4 | 4 |
Pharmacist Focus Group Interview | 3 | 1 |
Subtotal: | 7 | 5 |
Physician | ||
Head of Department | 2 | 2 |
Consultant | 1 | 1 |
Unspecified physician | 1 | 1 |
Registrar | 1 | 1 |
Medical officer | 5 | 5 |
Intern | 1 | 1 |
Subtotal: | 11 | 11 |
Total (N) | 36 | 28 |
CDI knowledge sorted by healthcare provider | |||||
---|---|---|---|---|---|
Occupation | Overall | ||||
Nurse (n = 11) | Physician (n = 11) | Pharmacist (n = 4) | All participants (n = 26) | ||
Median Score (0–7), [1st, 3rd interquartile] | 1 [0, 2.5] | 5 [4, 6] | 0.5 [0, 1] | 3 [0.25, 4.75] | |
Knowledge Classification, n (%) | |||||
No | 6 (54.5) | 0 (0.0) | 4 (100.0) | 10 (38.5) | |
Limited | 4 (36.4) | 0 (0.0) | 0 (0.0) | 4 (15.4) | |
Moderate | 0 (0.0) | 6 (54.5) | 0 (0.0) | 6 (23.1) | |
Advanced | 1 (100.0) | 5 (45.5) | 0 (0.0) | 6 (23.1) | |
Knowledge assessed in each CDI knowledge category | |||||
Components of CDI knowledge assessment, n (%) | |||||
1. Identification | 1.1 Characteristics of bacteria | 2 (18.2) | 4 (36.4) | 0 (0.0) | 6 (23.1) |
1.2 Risk factors | 3 (27.3) | 10 (90.9) | 0 (0.0) | 13 (50.0) | |
1.3 Signs and symptoms | 3 (27.3) | 11 (100.0) | 2 (50.0) | 16 (61.5) | |
2. Diagnosis | 2.1 Diagnosis | 1 (9.1) | 10 (90.9) | 0 (0.0) | 11 (42.3) |
3. Treatment | 3.1 Treatment options | 1 (9.1) | 7 (63.6) | 0 (0.0) | 8 (30.8) |
4. Prevention | 4.1 Hand washing needed | 4 (36.4) | 7 (63.6) | 0 (0.0) | 11 (42.3) |
4.2 Need for contact isolation | 4 (36.4) | 8 (72.7) | 0 (0.0) | 12 (46.2) |
Section I: Workflow
Identification and healthcare provider knowledge
“It’s actually the first time that I hear about it, to be honest” - Pharmacist
“When I was in the UK [United Kingdom] years ago… [when] the manager mentioned C. diff the staff would jump up and down and get incredibly panicky… we just don’t have that sense of urgency here… if you mention to someone in any hospital, they will go ‘Okay, what is that?’ [in cavalier tone]... however, if you tell them there is a patient with a potential XDR-TB [Extensively drug-resistant TB], then they may jump up and down. So the whole thing with C. diff it’s a reality… …a lot of people just think it’s a disease with the elderly, but we have a lot of immunocompromised patients…” - Physician
“In terms of my junior staff, I think [CDI] ranks quite low. I think it’s got to do with the way we’ve become aware last year. We’ve had more cases making us aware that it’s highly infectious.” - Physician
Diagnosis
“Most of the time they are not tested, because they come from the emergency, and because our emergency is so busy, then the patient is pushed up to the ward. So then only when the patient is in the ward, and then we are actually reporting the [diarrhoea] to them [post call]. And then report that the patient is having diarrhoea; then that’s the only time that they collect a stool specimen, and then after some, a couple of days, they get the results: the patient is positive. See... It could be about a week.” - Nurse Focus Group
“I think the one resource that we’ve shown very well is the communication system. I think we chose the cheapest one we could find which is WhatsApp and that does make a difference in terms of managing your patients and getting a quicker diagnosis. The thing about WhatsApp is if a patient had a positive result, it would take the doctor another 2 days to figure it out that an infection exists. We actually have an alert system that works.” - Physician
Treatment
Communication barriers were attributed to delays in treatment and included factors such as results being finalized while the physician was post call and drug order errors needing clarification.“So patients who don’t respond to metronidazole would definitely be candidates for vancomycin or a metronidazole allergy.” - Physician
“The problem with this is ...that sometimes the results come back, the doctor is post call. Yes, and then he will only get the feedback the next day when he is actually coming to check on his patients. So that is the delay to start”- Nurse Focus Group
Prevention: Contact precautions, hand hygiene, isolation, environmental cleaning
“...any patient with diarrhoea is placed with contact precaution; until we know if they have been exposed to any antibiotics, we put them as high risk.” - Physician
“I think that from all of it, that is where the biggest failing comes in—that we often don’t tell patients enough of the stuff. So, I would like to think that once it’s done there is a proper [communication] about the patient having things that can be transmitted, with words that they can understand and the importance of them not going around and touching lots of things and letting them know the reasons for gloving up and putting on gowns and stuff for their own peace of mind…It’s apathy from the medical staff we forget to do these things...” - Physician
“...have to use soap and water, we take [the] de-germ [alcohol based hand sanitizer] away from bedside so they are forced to use soap and water.” - Physician
“I would not say a normal hand soap is better for C. diff, I would say something alcohol based.” - Physician
Participants described hand hygiene events (e.g. ultraviolent light, blue soap) in their hospitals that encouraged effective hand hygiene. Many stated that overcrowding and lack of facilities (e.g. one sink per ward) hindered hand hygiene as well as: the high ratio of patients to nurses, education limitations, and sometimes-empty alcohol and/or soap dispensers.“Can I tell you, all over the basins is that sign [WHO’s “5 Moments of Hand Hygiene”]… but we don’t practice it...We don’t follow five moments of Hand Hygiene. We follow it when we go home... You can’t afford to take that 5 min.” – Nurse Focus Group
“The fact that we have got a lot of immunocompromised patients in terms of our HIV rates and TB rates, a lot of our patients are at risk due to the use of antibiotics. In the UK we used to see a lot of elderly patients, but here you have got a different spectrum of patients, so C. diff is a huge risk… I think everyone focuses on MDR and very few people actually focus on C. diff … C. diff is not something that is high on the radar.” - Physician
“The big problem that we have in our wards is a lack of isolation facilities. For an entire hospital, we’ve got only four isolation rooms [that] do not include isolation bathrooms. So a C. diff patient would have to use the same toilet as other patients.” - Physician
“Sometimes you’ll find the patient doesn’t know what is going on, but when you move them into an isolation room then they want to know why.” - Nurse
“It’s just that we are busy so the beds are always in demand so sometimes there is no opportunity for cleaning because everything is rush, rush, rush, rush. When the patient is waiting on discharge, others are waiting for that bed so we don’t have the opportunity to do the spring cleaning of the unit. We aren’t always able to do it in a calm environment.” – Nurse
Section II: Organizational Culture
Change culture: how leadership and administration respond to new ideas
“Implementing change and practical change are very different, so we are able to change our practice so we can make lots of suggestions... but the difficulty comes in that our staff [is a] rotating staff.” - Physician
“The people above me, the specialist physicians or consultants, are quite open to change. If you can show clearly that an idea is going to work, the department is open to change and improving things. As you get higher up the leadership chain, it becomes more difficult to introduce change. I do find that on the face of it, the managers seem to be okay and accepting and are happy to listen.” - Physician
Responsibility and accountability
“It seems we have many awareness days… we had spike last year, 2 years ago… we have had quite a few staff members contracted tuberculosis… people only get aware if their buddy gets it… It makes it real.” - Physician
“Just to get the doctors to wear gloves—that for me is another thing where I can just say… like, ‘Why are you not wearing gloves?’ or, just tell them ‘Your patient has TB. Can you put on your mask please?’ ...together with the hand washing, and at the end of the day, it is part of the IPC principles to have full personal protection equipment available in the unit, but there’s hand sanitizers, soap, and water, available in the unit, so no one has an excuse.” - Physician
“The cleaning staff and the nursing staff is quite well informed as to what is supposed to happen, because sometimes they can tell you. ‘Sister, this was not done yet; You can’t really put your patient here’… Those are the people that I work with... that I come across, that will tell me. Doesn’t matter if you are the cleaner, you can tell me, ‘Sister, it’s not ready yet.’ You understand. It’s that relationship that we have [of a] multidisciplinary team, to do what is expected of us.” – Nurse