This page is a collection of resources for Guides to Patient Safety (GPS) as outlined in the appendix of Preventing Hospital Infections (2nd Edition) by Drs. Jennifer Meddings, Vineet Chopra, and Sanjay Saint.

​These resources are broken down into the following sections: Catheter-Associated Urinary Tract Infection (CAUTI), Central Line-Associated Bloodstream Infection (CLABSI), and Clostridioides difficile Infection (CDI).
CAUTI GPS Funding
This tool was developed by faculty and staff from the Department of Veterans Affairs and the University of Michigan using funding support from the Department of Veterans Affairs, the University of Michigan, and the National Institutes of Health (NIH). This tool was validated and disseminated using funding support from the Agency for Healthcare Research and Quality (AHRQ), the Department of Veterans Affairs, and the University of Michigan.
CLABSI GPS Funding
This tool is modeled on the CAUTI GPS and was adapted by a team that included subject matter experts affiliated with the University of Michigan and Department of Veterans Affairs and funding support from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC).
CDI GPS Funding
This tool was developed as part of the STRIVE collaboration. Funding was provided by the Centers for Disease Control and Prevention, STRIVE Program (contract number 200-2015-88275), and project support was provided by the Health Research & Educational Trust, Department of Veterans Affairs, and the University of Michigan.
  • CAUTI
  • CLABSI
  • CDI
<
>
Data Collection
Collecting and comparing data both before and after an intervention provides an objective way to evaluate if your interventions are successful in reducing unnecessary catheter days and catheter-associated urinary tract infection (CAUTI). Ongoing assessments allow you to assess if the intervention is sustained.

1. The what and when of data collection
  • What to collect
    • ​Presence of a Foley
    • Explanation for its original insertion or continued use
    • Number of symptomatic CAUTI
  • When to collect it
    • At baseline: daily for 2 weeks (phase one)
    • During implementation: daily for two weeks (phase two)
    • After implementation: one day a week for 5 weeks (phase three)
    • During sustainability: daily for one week each quarter (phase four)

2. Calculations you should make from the data you collect
  • Process measure
    • Catheter utilization rate: Total # catheter-days/Total # patient-days X100
  • Outcome measure
    • NHSN measure: # of symptomatic CAUTI/1,000 urinary catheter days as measured in NHSN
    • Population-based measure: # of symptomatic CAUTI/10,000 patient days
  • Additional measures to consider
    • Unnecessary Urinary Catheter %: # of unnecessary catheter-days/Total # catheter-days X100
  • More information about these calculations is available at the CatheterOut website

3. It is important to apply a consistent approach to data collection at all stages of your prevention program so that you can compare across time periods and units.
4. Ensure that you have someone on the team who is responsible for collecting data
  • This is typically an infection preventionist or a member of the quality improvement department.
  • Responsibilities of this team member include:
    • Collecting and collating information–specifically, the presence of a Foley, the explanation for its original insertion or continued use, and any indication of a healthcare-associated urinary tract infection.
    • Feeding it back to the floor unit involved and to the hospital office responsible for sending the results to the CDC.

5. Further Reading Suggestions
6. An example data collection process currently used by several hospitals
Infection Prevention Feedback
Actively communicating with and providing timely and useful feedback to staff is an important part of quality improvement. Many hospitals have found that the transparency of sharing as much information as possible with the staff can help staff stay motivated and engaged in the quality improvement initiative.

​1. Data that should be fed back to frontline staff
  • What to collect
  • Data from the intervention
  • Any comparable data from nearby hospitals
  • Any comparable national data

2. Mechanisms for feedback
  • “Scorecard” that provides information on how performance is progressing toward goals
    • Can be provided at both the hospital and unit level
    • Should be visibly displayed throughout the hospital for all staff to see
  • Newsletters
  • Staff training
  • New employee orientation
  • E-mail Communications
  • Staff meetings

3. The key to effective feedback is not just the amount of information provided, but also how meaningful that information is for staff.
  • Do not limit feedback to numbers (e.g., CAUTI rate).
  • Provide details to make it more meaningful to the staff (e.g., we have gone X days since our last CAUTI).

4. Rewarding the staff or a unit for positive changes can be motivating. For example:
  • One site gave a little treat when a nurse initiated an early removal of a urinary catheter
  • Another site provided a pizza party to a unit that was able to get their high CAUTI rate down to zero

5. Further Reading Suggestions
Catheter Necessity and Removal
Because the necessity of an indwelling urinary catheter may change while a patient is in the hospital, it is imperative to continually assess its appropriateness. Daily assessment of catheter necessity is perhaps the single most important method of decreasing catheter use and subsequent infection.

1. Remind/educate your staff
  • Urinary catheters are often placed unnecessarily, remain in place without physician awareness, and are not removed promptly when no longer needed.
  • Prolonged catheterization is the strongest risk factor for catheter-associated urinary tract infection (CAUTI).
  • Promptly removing unnecessary catheters is an important step in reducing a patient’s risk of CAUTI.

2. Indwelling urinary catheters should be addressed daily
  • If nurses are concerned that they will have to spend more time cleaning up patients if the indwelling urinary catheter is removed, try:
    • Timed voiding or hourly intentional rounding
    • Exploring incontinence products, urinals, condom catheters, and intermittent straight catheters
  • If there is a general feeling of being overworked (”just trying to get through my shift”), try:
    • “Catheter patrol” - One or two daytime charge nurses who monitor which patients have indwelling urinary catheters, assist with toileting, and assess the indications for urinary catheters. If the indwelling urinary catheter is no longer clinically indicated, the “catheter patrol” can talk with the bedside nurse or ask the physician directly to discontinue.
    • Daily assessment tool - Tailored to the care setting, bedside nurses (or the “catheter patrol”) can assess the indications for the continued use of indwelling urinary catheters and if no longer clinically indicated, nurses can discuss its removal with the physician. Click here for an example.
  • If there is no mechanism to trigger prompt removal, consider these options:
    • Stop orders that prompt catheter removal by default after a certain time period or a set of clinical conditions has occurred (such as 24 or 48 hours post-operative) unless the catheter remains clinically appropriate.
    • A nurse-initiated removal protocol—whereby a nurse can initiate the removal of the indwelling urinary catheter by contacting the physician if after assessment an indication for continued use has not been identified.

3. For more information
  • For the current appropriateness guidelines, see the Ann Arbor Criteria.
  • More information and examples of nurse driven protocols to evaluate and discontinue unnecessary urinary catheters are available in this PDF at the CatheterOut website.
  • For more information on daily evaluation of urinary catheter appropriateness, see the information under the section called "Infection Prevention Feedback."

​4. Further Reading Suggestions
Patient Education
Educating patients and their family members about the importance of urinary catheter risks can be an important way to reduce the unnecessary use of urinary catheters.

1. Patients and families may believe that the use of indwelling urinary catheters is in the patient’s best interest, however we have found that this is often based on incomplete, and sometimes incorrect, information. It is important to educate your patients and their family members about the risks of a Foley, the benefits of early removal, and alternative toileting options.
2. For other resources, please visit:
​3. Further Reading Suggestions
Appropriateness
In the hectic and unpredictable environment of the emergency department (ED), physicians and nurses properly see themselves as serving on the front lines. Nurses and doctors are more concerned about whether their patients are still breathing than about whether they have a catheter. It takes a member of the catheter-associated urinary tract infection (CAUTI) prevention team to convince the ED that catheters count.

​1. Indwelling urinary catheters are commonly placed automatically in the ED
  • The CAUTI prevention team should include emergency department personnel (e.g., emergency medicine physician and nurse) when the initiative moves to the ED.
  • With the emergency medicine physician leading the way, the ED staff should be convinced to ensure a patient’s condition warrants an indwelling catheter, and to consider safer alternatives such as a condom catheter and bladder scanner with intermittent straight catheterization.

2. Upon hospital admission, the indwelling catheter often remains in place
  • The project leader can share the latest data from the medical unit(s), showing how many of the floor’s Foleys started out in the ED, what percentage were for inappropriate indications, and what percentage led to infection.
  • It is helpful to establish clear guidelines for urinary catheter use in the ED and to educate the staff on the appropriate indications for the catheter and how to use aseptic insertion technique in those patients who truly need the catheter.
  • We have found that the most effective approach is for the project manager and/or the nurse champion (ideally in this case the nurse champion is an ED nurse) to spend a part of each day walking through the ED, reminding everyone they see about the intervention, asking a nurse or a physician whether the Foley they are about to insert is really necessary (i.e., whether it meets the appropriateness criteria). It is especially important to identify patients being admitted to the hospital from the ED to reassess if the indwelling urinary catheter is still appropriate.

3. For more information on urinary catheters and the ED, see “Appropriate urinary catheter placement in the emergency department,” prepared by our team and funded by the Agency for Healthcare Research and Quality (AHRQ).

4. Further Reading Suggestions
Urinary Catheter Appropriateness Criteria
Without a list of clinically appropriate indications for urinary catheters, patients may be receiving urinary catheters for unnecessary reasons, in which case they have a higher risk of harm than benefit.

#. Further Suggested Reading
​​
Alternatives to Indwelling Urinary Catheters
External urinary catheters ought to be used as an alternative to indwelling urinary catheters, as indwelling catheters present a higher risk of infectious and non-infectious complications. External catheters are a safer alternative, and have grown in usefulness in recent years as new urinary catheter options have been developed for both men and women.

#. Further Suggested Reading
Identifying a Team
Because your catheter-associated urinary tract infection (CAUTI) prevention team is responsible for defining, designing, leading, and sustaining the initiative, it is crucial that it functions well. 

"For the change effort to be successful a powerful group must lead the change; and members of that group must work together as a team. Key characteristics that must be represented on the team include power, leadership skills, credibility, communications ability, expertise, authority, analytical skills, and a sense of urgency." (From TeamSTEPPS)

1. Team Membership
  • The composition of the team is important for the success of the initiative. We suggest that the team–at a minimum–include:
    • Team leader/project manager: When selecting a team leader, consider whether s/he has successfully led another quality improvement project. Leadership and management skills, and previous success are more important than the job title or content expertise. 
    • Nurse champion: When selecting a nurse champion, consider someone who is well respected and in a position to obtain support from the other nurses given that avoiding catheter use may be perceived as additional nursing work (monitoring indwelling urinary catheter placement, increased toileting time, and possible data collection). We believe that having an effective nurse champion is critically important to the success of your initiative! We have more information on overcoming a lack of/or challenges with a nurse champion at CatheterOut.org. (Select Engaging Providers tab and then Nurse Engagement.)
    • Physician champion: When selecting a physician champion try to involve a physician who is highly regarded. If finding someone who is able to be actively engaged in the process is not possible, then consider selecting a respected physician who is willing to lend their name to this initiative. We have more information on overcoming a lack of/or challenges with a physician champion at CatheterOut.org. (Select Engaging Providers tab and then Physician Engagement.)
    • Data person: Because the success of the intervention will be determined by the data, this person is a key component of any team. They are responsible for collating information-specifically, the presence of a Foley, the explanation for its original insertion or continued use, and any indication of a healthcare-associated urinary tract infection—and feed it back to the floor unit involved and to the hospital office responsible for sending the results to the CDC. This is often an infection preventionist, quality manager, or patient safety officer and it is common that s/he is already collecting and reporting the data to the internal leadership and for public reporting. For further information, see Data Collection (above).
  • Other important team members can include a member of the senior leadership, a nurse educator, an infection preventionist, and a quality improvement officer.
  • Ideally the team will be composed of members with different backgrounds and various levels of experience.
  • Despite the possibility that the initiative may take place over many units, we suggest that there only be one CAUTI Prevention Team.

2. What the Team Does
  • The team must take ownership of the initiative.
  • Team members must meet on a regular basis (we suggest biweekly to begin).
  • They must develop and implement an initiative, which will involve educating healthcare providers of the existing evidence and severity of catheter complications. 
  • They must collect data and feed it back to the unit.

3. Information and Exercises for Team Evaluation and Improvement 
4. Further Reading Suggestions
Identifying a Team Leader
Because the project manager (also referred to as the team leader) is responsible for coordinating and facilitating meetings, team communication, and overseeing that members understand their roles and follow through on their responsibilities, it is imperative that s/he has dedicated time to commit to the project.

1. If nobody has been identified for this role
  • Ask senior leadership for advice about who they recommend and who they can provide with some protected time to do this work.
  • Find someone who has been successful in coordinating a quality improvement initiative.
  • Experience and knowledge of the topic is secondary in importance to leadership skills, enthusiasm, persistence, and credibility. The leader will be expected to reach out to the content experts for guidance related to the technical aspects of the work.

2. If the selected project manager is not as effective as necessary
  • Check to see if they have been given dedicated time to work on this particular project. If not, engage leadership to help with this.
  • They may be lacking some of the necessary skills. We have found that coaching them on what they can improve upon can be very helpful. 
  • They may not be a good fit for the initiative, and it may be time to consider replacing them with someone else.

3. For a better understanding of what makes a project manager successful
4. Further Reading Suggestions
  • ​Cannon-Bowers, J. A., S. I. Tannenbaum, E. Salas, and C. E. Volpe. "Defining competencies and establishing team training requirements". Team effectiveness and decision-making in organizations. Ed. R.A. Guzzo, E. Salas, and Associates: San Francisco: Jossey-Bass, (1995)333.
  • Salas E, Burke CS, Stagl KC. "Developing teams and team leaders: strategies and principles." Leader Development for Transforming Organizations. Ed. R. G.Demaree, S. J. Zaccaro, and S. M. Halpin: Mahwah, NJ: Lawrence Erlbaum Associates, Inc, (2004).
Identifying a Nurse Champion
Because a catheter-associated urinary tract infection (CAUTI) initiative is especially dependent on nurses, an effective nurse champion is key. By effective, we mean: well respected and trusted by peers, supportive of safety, and an agent of change.

1. If a nurse champion is not yet identified
  • The most successful nurse champions are those that know their way around the hospital hierarchy but are independent-minded in terms of finding solutions. S/he must be on good terms with her colleagues.
  • Think twice about having a nurse executive or the director of nursing take on this role as there is danger that the bedside nurses may view the initiative as another occasion for obeying the boss.
  • Some qualities that make a successful nurse champion include: being personable, enthusiastic, empathetic, and having great communication skills.
  • There is no “one-size-fits-all” strategy. You must identify the type of individual that will work best in your organization.
  • Consider a nurse manager, nurse educator, and even a respected licensed practical nurse who others go to for advice.
  • Consider having co-champions if necessary.
  • Far more than the physician champion, the nurse champion is the face of the project to the people most instrumental in the project’s success, the bedside nurses.

2. If the nurse champion on your team is not as effective or engaged as needed
  • As with other members of the team, we have found that often the nurse champion has not been given dedicated time to work on this particular project. Supporting the nurse champion (e.g., reducing some of the clinical commitments in order to address the quality improvement project) during the initial stages may help with implementation efforts.
  • If the nurse champion has the dedicated time but is lacking some of the necessary skills, we have found that coaching him/her can be very helpful. The ideal coach may be the senior leader who is tracking the outcome of this project.
  • It is important to choose the champion based on his/her commitment to the issue and interest in safety. If it is clear that the nurse champion is not a good fit for the initiative (s/he may have been appointed rather than recruited), it may be time to consider replacing the nurse champion.
  • It is also important to recognize the nurse champion for his/her efforts via such mechanisms as certificates of recognition, annual evaluation appraisals, mention in newsletters, and acknowledgement from the Chief Nursing Officer.
  • We have also found that identifying and enlisting others who are either already engaged in this initiative or eager to improve patient safety can help support the efforts of the nurse champion. 

3. For more information on nurse engagement, visit CatheterOut.org.
  • Select Engaging Providers tab and then Nurse Engagement

4. Further Reading Suggestions
Identifying a Physician Champion
Because catheter-associated urinary tract infection (CAUTI) prevention efforts require collaboration and support of both physicians and nurses, an effective physician champion can be important.

1. To identify a physician champion
  • There is no “one-size-fits-all” strategy. You must identify the type of physician that will work best in your organization. Some suggestions include hospital epidemiologists, hospitalists, infectious diseases specialists, and urologists. Beware of choosing people on the basis of their job title. Unfortunately, titles don’t guarantee that a person will be appropriate for this task.
  • Our experience has been that the most successful physician champions are those that have pride in the hospital’s culture of excellence or concern over the lack of one. Ideally they are ideally a person who has the ear of the hospital administration and the respect of his or her peers, a doctors’ doctor, and someone who has the patience to hear out people who disagree with his or her point of view.
  • Because many physicians are not employees of the hospital and convincing a physician, employee or not, to take on any extra work is likely a tough assignment, we suggest the following: 
    • While we do not believe that paying doctors to take part in a patient-centered intervention is necessary or preferred, we see no problem with
      • Temporarily relieving the physician of some of his/her responsibilities
      • Or as was done in one hospital, recognizing a member of the medical staff with a “physician champion” award, complete with a certificate signed by the hospital’s chief of staff and a gift certificate to a local restaurant.
    • Assure the physician champion that their role will not take too much of their time. They should not, for example, be expected to attend all meetings or be otherwise involved in matters unrelated to clinical concerns such as budget discussions or internal promotional plans or working out details of data collection, unless of course they want to be. Their chief responsibility will be to share the details of the intervention with colleagues and gain their cooperation.

2. If the physician champion on your team is not as effective or engaged as needed
  • In institutions where there are good nurse-physician working relationships, most physicians may be willing to go along with recommendations by nurses, especially if the new practice is viewed as a “nursing initiative.”
  • As with other members of the team, we have found that in many instances the physician champion has not been given dedicated time to work on this particular project.
  • Make sure that medical leadership supports the initiative.
  • A ‘strong’ physician champion may not be entirely necessary if both nurses and medical leadership supports the initiative and there is no active resistance from physicians.
  • Find a member of the ‘tribe’. “Surgeons are very tribal,” the chief of staff said, discussing the difficulty an infection prevention leader (an internist) might have trying to bring his message to a group of surgeons. “The first thing we’re going to do is we’re going to say, ‘Look, you’re not one of us.’ The way to get buy-in from surgeons is you got to have a surgeon on your team.”

3. Further Reading Suggestions
Damschroder LJ, Banaszak-Holl J, Kowalski CP, Forman J, Saint S, Krein SL. The role of the champion in infection prevention: results from a multisite qualitative study. Qual Saf Health Care. 2009;18(6):434-40.
Fakih MG, Krein SL, Edson B, Watson SR, Battles JB, Saint S. Engaging healthcare workers to prevent catheter-associated urinary tract infection and avert patient harm. Am J Infect Control. 2014;42(10Suppl):S223-9.
Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging physicians in a shared quality agenda. IHI Innovation Series white paper. 2007. Cambridge, MA: Institute for Healthcare Improvement.
Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study. Infect Control Hosp Epidemiol. 2010;31(9):901-7.
Senior Leadership Support
It is helpful if hospital administrators and clinical chiefs take on personal leadership roles in quality improvement initiatives. With some extra effort they can help build powerful support for the catheter-associated urinary tract infection (CAUTI) prevention project. Ideally, one member of the executive leadership team will be primarily responsible for overseeing the CAUTI initiative at your hospital. In our experience, this often is the chief nursing executive.

1. To engage leadership
  • Prepare and present a business case to help convince leadership that the time and resources for implementing the new practice will be worth it.
    • The CAUTI Cost Calculator estimates your hospital’s costs due to CAUTI. It can be used to estimate both the current and projected costs after a hypothetical intervention to reduce catheter use.
  • Be sure leadership receives monthly CAUTI rates and catheter use data.

2. Ways that leadership can show their support
  • Mention in meetings and other staff encounters that these prevention activities are a reflection of the hospital’s mission
  • Stop by and listen in to a reporting session on the initiative, thus boosting the team’s sense of purpose
  • Include updates on the project’s progress in their hospital-wide newsletter and online communications
  • Make the degree of a person’s support of quality initiatives a regular element of employee performance reviews
  • Top supervisors can provide backing when those leading an initiative run up against immovable road blocks

3. Further Reading Suggestions
Nurse Engagement
In a catheter-associated urinary tract infection (CAUTI) prevention program, the nursing staff, especially frontline staff, are central to the success of the initiative. Because they are the staff whose day-to-day activities are most affected by the changes, they may present the greatest resistance.

1. Reason for the resistance
  • Because resistance can occur for a number of different reasons, as a first step we suggest interviewing front-line staff to learn why they are resistant to implementing a CAUTI prevention program and what, in the opinion of staff, is needed before acceptance of the program can occur.

2. Strategies for enhancing nursing engagement and decreasing potential resistance
  • Get a volunteer from the nursing staff to be a change champion for each shift—someone who other staff respect and who is committed to the process (examples include a front line nurse or a nurse educator).
  • Get buy-in before implementation. For example, ask, “Whom do we have to convince on this floor?” Have that person help to develop the plan and/or participate in the education for that unit.
  • Provide regular feedback on progress, as well as monthly reports on urinary catheter prevalence, and CAUTI rates.
  • Encourage nurses to be creative, developing visual cues to stimulate interest and keep the CAUTI initiative a top priority.
    • One site posted flyers/banners on the unit, such as “This is a catheter out zone.”
  • Make sure to listen and clearly understand nurses’ concerns and address them to the nurses’ satisfaction. This may require some education of the staff, creativity, or reallocation of resources.
  • Consider changes to (or redistribution of) workload.
    • For example, one site instituted a “small zone” so that nurses could be given a somewhat lighter workload when assigned to a patient who needed help with frequent toileting.
    • Another strategy is to prioritize nurse assistant/tech tasks to toileting patients.
  • Bring the education to the bedside. Do competencies on the unit, talking with nurses one-to-one during the point prevalence assessments.

3. For more information, see CatheterOut.org
  • For nurse engagement, select the Engaging Providers tab, and then Nurse Engagement.
  • For barriers and solutions, select Engaging Providers tab, then Barriers and Possible Solutions. 

4. Further Reading Suggestions
Physician Engagement
Because the day-to-day operation of a quality improvement project requires the ability of staff to adopt new goals and practices, it is important that the physicians either embrace, or at a minimum do not resist the implementation of catheter-associated urinary tract infection (CAUTI) prevention activities at your site/unit.

1. If there are some physicians who are resisting the initiative
  • Educate them on the clinical and economic consequences of continuing the status quo.
    • Clinical consequences are both infectious and non-infectious. CatheterOut.org provides more information on clinical consequences. There are sections for both Infectious and Non-infectious Complications.
    • The CAUTI Cost Calculator estimates your hospital's costs due to CAUTI. It can be used to estimate both current costs and projected costs after a hypothetical intervention to reduce catheter use.
  • Provide data to physicians about Foley use, highlighting:
    • how often physicians have a patient with an indwelling urinary catheter and forget about it
    • monthly Foley incidence
    • CAUTI rates
  • Engage medical leadership support by discussing the issue of CAUTI with the chief of staff (or chief medical officer) who in turn can, as needed, have a frank conversation with physician resistors.
  • Involve the physicians as much as possible in the planning, education, and implementation of the project.
  • Identify and discuss specific reasons why catheter use might be of interest for a given type of physician.
    • For example, a geriatrician might be inclined to support catheter removal given that urinary catheters increase immobility and is a deconditioning risk for their already frail patients.
  • If you are still struggling with CAUTI efforts related to physician engagement, it may be useful to determine the type of people-related issues you may be confronting: active resistance, organizational constipation, and time-serving.

2. For more specific suggestions for engaging physicians, visit CatheterOut.org.
  • Select Engaging Providers tab and then Physician Engagement.

3. For existing presentations, fliers, and pocket cards, visit CatheterOut.org.
  • Select Educational Tools tab and then Presentations.

4. Further Reading Suggestions
5. For an example of one hospital’s success at overcoming this barrier, visit CatheterOut.org. 
Data Collection
You indicated that you do not currently collect data related to CLABSI prevention such as number of central venous catheters, days of use or rates of infection. To successfully prevent CLABSI, reliable and actionable data that clearly points to a problem and solution is key. Measurement of data that is unit- and patient-specific is necessary in order to identify outliers, trends in infection rates as well as the efficacy of interventions. The Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) module and Targeted Assessment for Prevention (TAP) Strategy tools provide overviews of how these data can be collected, reported and used to guide improvement.

Tools, Resources and Further Reading
Infection Prevention Feedback
You indicated that you do not routinely feedback CLABSI-related data to frontline staff. While collecting CLABSI-related data is key to measuring the success of the intervention, it is imperative that the staff, especially those on the frontline are aware of successes and failures. Sharing data is therefore imperative to not only motivate, but also engage the staff at all stages of the CLABSI prevention work. Having access to timely data will also encourage staff to continue changes for sustaining reductions in CLABSI.

Tools, Resources and Further Reading
Aseptic Insertion
​You indicated that your facility either does not use a standardized CVC insertion tray or does not use one that contains chlorhexidine gluconate for skin antisepsis. Multiple studies have shown that the creation of a standardized tray that includes key equipment (e.g., introducer needle, guidewire, micro-puncture kit, antiseptic) helps prevent breaks in sterile procedure when inserting central lines. Additionally, use of alcohol-containing chlorhexidine as a skin antiseptic has been shown to reduce rates of CLABSI in multiple randomized trials and systematic reviews. Thus, these two measures are key to preventing CLABSIs.

Tools, Resources and Further Reading
Nurse Empowerment
​You indicated that nurses are not empowered to stop CVC placement if aseptic insertion technique is broken or not being followed. Empowering nurses to stop CVCs from being placed when aseptic insertion is not being followed is a key step to reducing CLABSI. The Michigan Keystone study found dramatic reductions when nurses not involved with device placement, monitored CVC insertion at the bedside and stopped the procedure if maximal sterile barriers and other antisepsis measures were not being followed. Encouraging nurses to speak up and developing a culture of patient safety such that this type of feedback is not only encouraged, but also appreciated is an important step in preventing CLABSIs.

Tools, Resources and Further Reading
Catheter Necessity and Removal
You indicated that bedside nurses either do not take the initiative or do not contact physicians to ensure that CVCs are removed when no longer clinically necessary. Each day with a CVC increases the risk of infections such as CLABSI. An effective way to prevent CLABSI, therefore, is to review the necessity of a central line every day and encourage removal of devices that are idle and not being used, clinically unnecessary or no longer clinically indicated, e.g., the reason for CVC is no longer relevant. Multidisciplinary rounds and processes that encourage clinicians to continuously reassess central line necessity can substantial impact central line utilization and reduce CLABSIs.

Tools, Resources and Further Reading
Catheter Maintenance
You indicated that bedside nurses either do not assess vascular catheter dressing integrity on a daily basis or do not replace loose, wet or soiled dressing when observed. Care of the catheter exit site is vital in the prevention of CLABSI. Semi-transparent dressings or dressings containing antiseptics are key to preventing bacterial migration from the skin to the bloodstream. Any factor that jeopardizes the integrity of the dressing can increase the risk of CLABSI. Daily rounds that examine catheter entry sites, ensure that the dressing is clean, dry and intact, and promptly address dressing issues that threaten the exit site can prevent maintenance-related infections. A well-functioning CLABSI prevention initiative often has a well-functioning vascular catheter care team that is constantly monitoring CVC care and maintenance practices. 

Tools, Resources and Further Reading
Patient Education
​You indicated that patients and families often request CVCs such as PICCs, in your facility. This phenomenon is a common and growing trend in the United States, especially as PICCs become more prevalent. Additionally, patients that might have received PICCs in the past (for appropriate or inappropriate indications) are likely to request this device again given the comfort associated with lack of needle sticks for blood draws. However, these devices are not without risks. Educating patients on the risks and benefits of CVCs as well as PICCs is therefore important. Partnering with medical providers such that the use of CVCs and PICCs occurs only for appropriate indications is an important step in preventing infection. The Michigan Appropriateness Guide to Intravenous Catheters (MAGIC) is one such document that can help inform this decision. 

Tools, Resources and Further Reading
Appropriateness
You indicated that CVCs, such as PICCs, are inserted without an appropriate indication in your facility. The best way to avoid a CLABSI is to avoid insertion of a central venous access device if it is not necessary. Partnering with medical providers such that the use of CVCs and PICCs occurs only for appropriate indications is an important step in preventing infection. Steps that include standardized list of indications, electronic medical record improvements to facilitate documentation of indication, or working with inserters of CVCs to ensure that the indication for use is documented can help improve use of CVC. The Michigan Appropriateness Guide to Intravenous Catheters (MAGIC) contains appropriate indications for use of CVCs such as PICCs and tunneled catheters.

Tools, Resources and Further Reading
Non-central Venous Catheters
You indicated that you do not have non-central venous catheter options available for insertion in patients with difficult venous access. Investing in peripheral venous access strategies for patients with difficult venous access, and ensuring that staff who insert these lines are trained and comfortable with these devices can help avoid unnecessary PICC use. 

Tools, Resources and Further Reading
Empowering Vascular Access Teams
You indicated that vascular access nurses are not currently empowered to insert the most appropriate device for a patient. Empowering vascular access nurses or teams to act as consultants ensures that appropriate choices are made about catheter insertion and devices, as these teams assess patients’ venous anatomy, infusion needs, and available access sites.   

Tools, Resources and Further Reading
Identifying Stakeholders
You indicated that either you do not have a team or the one you have does not function well for preventing CLABSI. A key aspect of implementing a CLABSI prevention initiative is developing a partnership between key stakeholders (e.g., intensive care physicians, hospitalists, anesthesiologists, interventional radiologists, vascular, bedside and intensive care unit (ICU) nurses) that insert and care for central lines. Ideally, stakeholders from these specialties should be engaged in improvement within an implementation team in your hospital or unit. This team plays a critical role in developing the CLABSI prevention initiative, assisting with implementation and monitoring CLABSI rates. Key responsibilities of this team are education, data collection and evaluation. Individuals can fill more than one role and some may be short-term and others longer-term. 

​Tools, Resources and Further Reading
Identifying a Team Leader
You indicated that either you do not have a team leader or that the one you have does not have appropriate time for CLABSI prevention. The team leader is responsible for coordinating the CLABSI prevention efforts – collecting data, organizing reports, presenting outcomes and tracking progress. It is their responsibility to keep the improvement moving forward and coordinate all the moving pieces between stakeholders. It is unlikely that the CLABSI prevention initiative is the only responsibility of the team leader, and because of this, there may not be enough time devoted to the prevention efforts. Creating that dedicated time is imperative to a successful initiative.

Tools, Resources and Further Reading
Identifying a Nurse Champion
You indicated that either you do not have a nurse champion or that the one you have is not effective when it comes to CLABSI prevention activities. Because nurses play key roles during CVC insertion (i.e., ensuring adherence to aseptic practice for CVCs or inserting PICCS), are solely responsible for care and management of vascular catheters and are critical members of multidisciplinary teams that review vascular catheter necessity on a daily basis, buy-in from this group of health care providers is key. The nurse champion is responsible for engaging nursing staff in CLABSI prevention efforts and working to integrate practices into daily nursing workflow. A nurse champion plays a large role in bringing the initiative to the nursing staff, but also in modeling excitement for infection prevention efforts and problem-solving as challenges arise. The nurse champion also forms a critical link between the multidisciplinary team, bringing frontline clinicians actionable data for change.

Tools, Resources and Further Reading
Identifying a Physician Champion
​You indicated that you do not have a physician champion for your CLABSI prevention activities or that the one you have is not effective. Having a physician leader that is respected amongst members of the clinical care team in your facility is an important part of the cultural aspect of overcoming CLABSI. Ideal physician champions are either those involved in the insertion of CVCs (e.g., critical care, surgery, interventional radiologists) or in ordering of devices (e.g., hospitalists). An effective physician champion plays a large role in bringing the initiative to the medical staff, modeling the positive excitement for CLABSI prevention and problem solving as challenges arise. The physician champion also forms a critical link between the multidisciplinary team, bringing frontline clinicians actionable data and strategies for change.

Tools, Resources and Further Reading
Senior Leadership Support
​You indicated that you do not have the support of senior leadership for your CLABSI prevention activities. Preventing CLABSI is no easy task and often requires additional material, support and staff to enable change. These types of initiatives are costly and often require the approval of managerial staff in departments such as medical executive leadership, purchasing and accounts. A key element that led to the success of the Michigan Keystone study was requiring senior leadership presence during CLABSI meetings so that data and action items could be reviewed and discussed with the multidisciplinary team. These meetings thus serve to ensure buy-in from those that may not have clinical roles, but make decisions regarding supplies and purchases. Given the many competing priorities of hospitals, having the support of leadership is key to making lasting progress with your CLABSI prevention initiative. Having a member of the hospital executive leadership team oversee the initiative also lets the hospital staff know the importance of the initiative.

Tools, Resources and Further Reading
Data Collection
You indicated that you do not currently collect CDI-related data. Collecting, measuring, analyzing and reporting information on your CDI prevention activities are critical to ensure continued success. Outcome data, such as total CDI burden, enable you to monitor the success of your CDI prevention initiatives and allow teams to compare how they are doing in their prevention efforts to other units and hospitals. Additionally, as health care moves from fee-for-service models of care to value-based compensation, healthcare-associated infection (HAI) rates, including CDI rates, are important metrics for determining care reimbursement. Process measures, such as hand hygiene compliance rates and the use of high-risk antibiotics, like fluoroquinolones, ensure that process interventions are being effectively implemented and point to areas that require continued enhancement or intervention. Lastly, sharing and highlighting data are crucial strategies for engaging physicians, frontline staff and senior leaders in infection prevention efforts.

A. What Data to Collect and When to Collect it
  • C. difficile infection standardized infection ratio (SIR): A measure used to track HAIs at the national, state and local levels and used by the Centers for Medicare and Medicaid Services (CMS) for their value-based purchasing program. The SIR compares the actual number of infections to the expected/predicted number of infections. Using the CDC’s National Healthcare Safety Network (NHSN) Targeted Assessment for Prevention (TAP) reports, you can use the SIR to calculate the cumulative attributable difference (CAD), which tells you how many infections a hospital would need to prevent in order to reach a particular infection goal.
  • Number of LabID hospital-associated C. difficile infections: Patients with stool samples that test positive for C. difficile four or more days after hospital admission.
  • Number of LabID non-hospital-associated infection or community-associated C. difficile infections: Patients with stool samples that test positive for C. difficile day three or sooner after admission to the hospital.
  • Recurrent C. difficile infections: Patients with stool samples that test positive for C. difficile more than 14 days (two weeks) but fewer than 56 days (eight weeks) after the most recent CDI LabID event for that patient.
  • Total antibiotic use: Track total antibiotic use, including type of antibiotic, dose and duration.
  • Appropriate antibiotic use: Antibiotics can either be tracked, as the antibiotics given for disease specific states or infections (e.g., urinary tract infection (UTI), pneumonia (PNA)), or the amount of prescribed antibiotics that are associated with a high-risk of CDI (e.g., fluoroquinolones).
  • Stool stewardship: Rates of rejection of inappropriate stool samples sent for CDI testing.
  • Environmental cleaning compliance rates: Compliance with institutional standards for daily cleaning procedures and discharge cleaning procedures.
  • Hand hygiene and PPE compliance rates: Compliance with institutional standards for hand hygiene and effective PPE use.

​B. Strategies for Successful Data Collection
  • Apply a consistent approach to data collection at all stages of your prevention initiatives so that you can compare across time periods and units.
  • Designate personnel responsible for data collection. This will typically be infection preventionists or members of the quality improvement department.
  • Review CDI line lists to monitor your hospital’s CDIs. Line lists for CDIs will give you a perspective on dates of onset of infection and locations within the hospital, providing some insight into potential opportunities to intervene, such as a particular unit with a high prevalence of infection. We recommend using the C. difficile lab ID (ergo, the date the stool specimen tested positive) to generate the line list.
  • Use the CDC NHSN TAP reports for tracking and monitoring CDI prevention efforts. Most hospitals already enter CDI data into NHSN, which calculates and compares hospitals’ HAI rates using the SIR. The TAP strategy is a way to identify facilities or units with the highest excess numbers of infections so that prevention efforts may be directed toward facilities or units in greatest need of improvement. The TAP report displays a CAD, which is the number of infections a facility or unit would need to prevent to reach the health and human services CDI reduction goal. The CAD helps hospitals and units use data for action by translating a target SIR into an HAI prevention goal. This provides a concrete goal to drive action and translates the SIR into a simple message for frontline health care workers.
  • Regularly feed data back to the entire CDI prevention team, senior leaders and frontline staff, including environmental services. Sharing data and highlighting success will help empower staff and encourage continued improvement and commitment to the initiative.

Tools, Resources and Further Reading
Infection Prevention Feedback
​You indicated that you do not routinely feed CDI-related data back to frontline staff. While collecting CDI-related data is key to measuring the success, it is imperative that the staff, especially those on the frontline, are aware of it. Data transparency can help motivate and engage staff at all stages of the initiative, as well as encourage them to continue the changes, promoting sustainability. Simply put, feedback improves motivation and engagement. Feed hospital initiative data back, as well as data from comparable hospitals and national aggregates. Simple run-charts or a CDI scorecard are great ways to quickly display and easily communicate data to both frontline staff and senior leaders.

A. Feedback Mechanisms
  • CDI Scorecard: Tracks hospital or unit progress towards achieving their CDI prevention goals; it should be displayed throughout the unit or hospital for all staff to see.
  • Hospital newsletters
  • Hospital electronic communications
  • Staff educational events
  • New employee orientation
  • Staff meetings 
  • Unit huddles

B. Keys to Giving Effective Feedback
  • For feedback to be effective, it should be:
    • Timely. Feedback should be at least monthly or more often if possible. If you wait too long to provide feedback, key details are forgotten and/or the feedback loses its meaning. 
    • Individualized. Feedback should relate to a specific situation, task, or individual. The more specific the feedback, the more the individual, unit, etc. will be able to correct or modify their performance to improve. 
    • Customizable. Feedback should be detailed to the improvement goals of the individual, unit or organization. Different processes or data should be shared or highlighted depending on the targeted improvement goals.
    • Non-punitive. Feedback should be about performance of a specific situation or task; it should never be personal. Rather, feedback should be about achieving improvement goals.
    • (From TeamSTEPPS Fundamentals Course: Module 3. Communication. Content last reviewed March 2014. Agency for Healthcare Research and Quality, Rockville, MD.)
  • ​Don’t limit feedback to numbers (e.g., just CDI rate); share details to help make it more meaningful. Consider sharing the days the hospital or unit has gone without a CDI. Consider using stories or pictures to help remind staff that each infection correlates to harm to a patient. 
  • When communicating CDI-related data to staff, consider the audience, and tailor what is shared to their needs. For example, complex rates or SIRs may be confusing for frontline staff, so instead, consider sharing new monthly CDI cases with ancillary unit staff; CDI rates and hospital SIR may be more appropriate to share with the infection preventionist and the infection prevention and control committee.
  • Highlight and celebrate infection prevention successes, no matter how small. Consider rewarding staff for positive changes or making steps towards their CDI prevention goals.

Tools, Resources and Further Reading
Education on Testing
​You indicated that clinicians are not educated as to when it is appropriate to order CDI testing. CDI is a clinical diagnosis; lab tests help support a clinical suspicion, but they should not be taken out of the clinical context. It is important that clinicians are educated and informed of high C. difficile colonization rates to illustrate that indiscriminate testing will lead to false-positive results.

A. Engaging and Educating Clinicians on CDI Testing Best Practices
  • Coordinating with the physician champion on the CDI team will be very important to help tailor the educational intervention aimed at improving physician CDI testing. There are many opportunities to provide this education, which include:
    • Physician CDI ordering scorecard: Tracking physicians’ ordering patterns and using these to provide feedback to the physicians can help them improve
    • Hospital newsletters and electronic communications
    • Best practice advisories/alerts built into the ordering system 
    • Unit-based educational sessions
    • New physician onboarding 
    • Resident training (if applicable)
    • Physician conferences
    • Clinical laboratory rejection of inappropriate samples
  • Ordering providers should be aware of many aspects of appropriately testing a patient’s stool for CDI. Some specific aspects include:
    • Patients who do not have clinically significant loose stools should not have testing for CDI.
    • Patients who are on laxatives that explains their loose stools should not have testing for CDI.
    • Patients should not be tested at the end of the antibiotic course to ensure that the CDI has resolved, except in epidemiological studies.
    • Physicians should be aware of the specific lab test that a facility uses to determine the presence of C. difficile (Antigen EIA, Toxin EIA, PCR) as well as what each test means.
  • Nursing staff should also have education about appropriate testing for CDI because they are often the ones that communicate the presence of diarrhea to physicians and ask for CDI testing. If they understand the testing for CDI, they are more likely to request lab tests only when clinically appropriate. 

Tools, Resources and Further Reading
Appropriate Testing
You indicated that your laboratory does not reject formed stools submitted for CDI testing. It is important to remember that CDI is a clinical diagnosis; lab tests help support a clinical suspicion, but they should not be taken out of the clinical context. In order to limit inappropriate testing, clinical laboratories can set a threshold on the type of stool that is acceptable for C. difficile testing.

A. Connecting Stool Stewardship and CDI Prevention
  • The crucial symptom of CDI is clinically significant diarrhea with loose stools. Coordinating with clinical laboratories to set a threshold on the type of stool that is acceptable for C. difficile testing can help to ensure that this standard has been met and will prevent inappropriate testing.
  • Stool stewardship can help drive down false positive rates and help prevent inappropriate antibiotic use on patients who are only colonized and do not actually have an active CDI.
  • The Bristol Stool scale is the most widely used standardization of stools to determine when CDI testing is appropriate. Coordinate with clinical lab personnel to ensure that they are familiar with these standards.
  • Empower lab staff to reject stool samples that do not meet recognized standards. It is important that the ordering clinician be informed of this rejection and its rationale. This can also be an effective educational intervention. 
  • Beyond testing only unformed stools, efforts should be made to ensure that there is no other explanation for the cause of the diarrhea. Studies indicate that between 19-40% of patients who are tested for CDI are currently receiving laxatives, which further cloud the clinical picture. 

Tools, Resources and Further Reading
Antibiotic Stewardship Teams
You indicated that you do not have at least one physician and/or one pharmacist engaged on your hospital’s antibiotic stewardship team. Inappropriate and avoidable exposure to antibiotics is the single most important risk factor for developing CDI. A successful CDI prevention initiative requires collaboration and cooperation with physicians and pharmacists. Physician and pharmacist champions can help bring the initiative to the other physicians and pharmacists, aid with engagement and be a part of problem solving when there is resistance or another challenge from providers.

A. Strategies to Connect CDI Prevention and Antibiotic Stewardship Efforts
Antibiotic stewardship programs not only help individual patients by avoiding exposure to inappropriate antibiotics but also have a multiplicative effect on helping to reduce CDI at the unit and even hospital level. At their core, antibiotic stewardship programs coordinate interventions designed to improve and measure the appropriate use of antibiotics by promoting the selection of the optimal antibiotic drug regimen, including dose, duration of therapy, and route of administration. Ensuring that your antibiotic stewardship team is effective is critical to reducing CDI rates.
  • Engage a physician champion and a pharmacist champion to lead antibiotic stewardship efforts, placing particular emphasis on routinely monitoring and discussing CDI rates, rates of antibiotic use and rates of high-risk antibiotic use (e.g., fluoroquinolones).
  • Reduce unnecessary exposure to broad-spectrum antibiotics, tailoring ongoing antibiotic use based on the latest clinical data and lab results.
  • Consider specific actions to optimize antibiotic use by implementing:
    • Interventions that occur across a unit, service or facility.
    • Specific interventions focused on particular infections or antibiotics.
    • Pharmacy or lab-driven interventions that are built into the ordering system. 
  • Implement a plan to communicate antibiotic use rational, dose and duration when patients are transferred between units and to other health care facilities.
  • Implement initial changes on a smaller scale as some facilities may be resistant to broad, sweeping changes.
  • Avoid implementing too many actions and interventions simultaneously; this may spread resources too thin and lead to staff confusion and resistance.
  • Consider what hospital characteristics may influence CDI prevention efforts, such as:
    • What are the underlying issues at your facility that are driving increased CDI rates?
    • What are unique characteristics of your facility or patient population that may affect initiative implementation? 
    • What is the institutional culture? 
    • What about timing? Will the intervention require significant lead-time? 

B. Strategies for Engaging Physician and Pharmacist Champions
  • There is no “one-size-fits-all” strategy to finding a physician or pharmacist champion. You must identify the type of physician who will work best in your organization. Some suggestions include: engaging clinicians who participate on the hospital Pharmacy and Therapeutics Committee, infectious disease doctors or hospitalists. If no one is available, consider reaching out to an off-site or “remote” leader. When selecting a physician champion, consider someone who is passionate about antibiotic stewardship and/or preventing CDI. Regardless of who is chosen, it is important to engage the Pharmacy and Therapeutics Committee early in the process and maintain ongoing communication. 
  • Often, successful physician and pharmacist champions are those who have pride in the hospital’s culture of excellence or are interested in making improvements. Ideally, this physician or pharmacist may have the ear of the hospital administration and the respect of their peers. They would be someone who is willing to collaborate with other disciplines and is open to differing viewpoints and perspectives. 
  • Because many physicians have clinical responsibilities and may not be employees of the institution, it is important to consider their workload when asking them to become a champion of this work. Consider the following suggestions: 
    • Be clear on the expectations for the physician champion at the beginning. The primary roles of the physician champion are to share details of the initiative with their colleagues and gain their cooperation and support to improve patient and safety outcomes. Physician champions should not, for example, be expected to attend all meetings, be otherwise involved in matters unrelated to clinical concerns, such as budget discussions or internal promotional plans, or work out details of data collection (unless they want to). 
    • Temporarily relieve the physician of some of their responsibilities. Develop some type of recognition for the physician(s). One hospital recognized a member of its medical staff with a “physician champion” award, complete with a certificate signed by the hospital’s chief of staff and a gift certificate to a local restaurant. 
    • Consider rewarding physicians who actively participate in infection prevention initiatives as champions. This can include financial compensation for the champion role and the extra time spent assisting with these efforts.
    • Consider having co-champions to lighten the workload and provide mutual support. A co-champion can be another physician or an additional pharmacist. Typically, clinical pharmacists have a great deal of credibility with the medical staff, and therefore, pairing a physician with a clinical pharmacist as co-champions to engage the medical staff can be a very effective strategy.
    • Include a champion’s activities towards his/her obligations to meet credentialing requirements for the hospital.
  • The pharmacist champion is likely an employee of the hospital, and duties related to antibiotic stewardship should be included in his or her routine responsibilities. Time and resources for this work will be necessary, and typically, the pharmacist will be tasked with much of the work to develop and implement an antibiotic stewardship program. The pharmacist champion should be involved in budgets, promotional work, and data collection strategies as they have the expertise related to pharmacy systems, the drugs themselves, and related costs that will be needed for data collection and tracking of outcomes. In addition, they are a key educator and champion to engage fellow pharmacists in this work and thus needs first-hand, tacit knowledge of the program.
  • Leadership commitment to the antibiotic stewardship program can be the deciding factor for pharmacist and physician involvement. To help get leadership buy-in, develop a strong business case highlighting the return on investment for involvement in antibiotic stewardship programs. Antibiotic stewardship efforts to reduce CDI can often pay for themselves through savings. This includes direct savings through decreased antibiotic costs and indirect savings through decreased costs of caring for patients who will subsequently not develop CDI. Make sure that medical leadership allows the physician and pharmacist champions dedicated time to work on antibiotic stewardship. 

Tools, Resources and Further Reading
Environmental Cleaning
​​You indicated that you do not conduct audits or provide feedback to staff on the effectiveness of environmental cleaning. Transmission of C. difficile is similar to other pathogens spread by contact; bacteria or bacterial spores can contaminate the patient or their environment and then be passed on to other patients via health care personnel or shared equipment, or to the next occupant of the patient room. A key aspect of preventing CDI is preventing C. difficile transmission. Hospitals and units need to ensure that environmental cleaning and disinfection are effectively decontaminating patient rooms and equipment.

A. Environmental Cleaning and Disinfecting Essentials for Preventing CDI
Transmission of C. difficile is similar to other pathogens spread by contact; the patient or patient’s environment can become contaminated, making it easy to spread C. difficile to other patients if the environment and equipment are not properly cleaned and disinfected. The formation of spores makes the removal of C. difficile more difficult than most pathogens, though their removal or deactivation is possible with thorough cleaning and disinfection.
  • Include environmental services staff as key members of the CDI prevention team. Emphasizing their important role in infection prevention will help create buy-in and may assist in highlighting alternative approaches for decreasing CDI transmission.
  • Train unit staff, as well as the environmental services staff, on how to clean the environment when C. diff is present. Patients with CDI will have frequent diarrheal stools, increasing the risk of patient environment contamination. Unit staff are often responsible for cleaning and disinfection of the patient environment and equipment when environmental services cannot arrive promptly and there is significant environmental soiling. Additionally, staff must be aware of how to properly clean and disinfect equipment and supplies that cannot be dedicated and/or are not disposable.
  • When selecting products for cleaning and disinfection, the following factors should be considered before implementing new products:
    • Level of disinfection required and the most appropriate agent or solution for the job. (Products should have label claims clearly indicating that the product inactivates Cdiff spores. Plain air will kill vegetative Cdiff organisms, but the spores are very hardy and must be deactivated to effectively halt transmission.)
    • Ease of use (contact time, mixing requirements, stability, method of delivery, etc.)
    • Safety (toxicity, flammability, etc.) 
    • Surface compatibility, persistent activity and odor
    • Accompanying products needed (mops, cloth, etc.)
    • Cost
    • Training and education
    • Potential barriers (product availability, staffing, workflow, etc.)
  • Cleaning and disinfecting protocols should place particular emphasis on high-touch surfaces, such as the bed rails, over-bed tables and call buttons, and should encourage staff to follow a pre-determined logical cleaning pattern, moving from cleanest to dirtiest. Checklists are useful to ensure all items are included in the cleaning and disinfection process and that everyone is on the same page about what “clean to dirty flow” means for hospital rooms, operating rooms, etc.
  • Use single-use or disposable supplies whenever possible. Examples of commonly used equipment for which single-use patient supplies may be substituted are stethoscopes and blood pressure cuffs.
  • For shared patient equipment, a plan for cleaning and disinfection that includes who is to clean the equipment, when, and how should be developed, posted and monitored.
  • Identify and address barriers to effective cleaning and disinfection (e.g., clutter in the patient room, lack of assigned responsibility for cleaning certain items).
  • Include mechanisms for monitoring compliance and thoroughness of cleaning.

B. Strategies for conducting audits and providing feedback on environmental cleaning effectiveness
  • Use evidence-based guidelines and regulatory standards to drive implementation of practices and determine auditing strategies to ensure safe and effective patient care. 
  • Audit environmental and equipment cleaning and disinfecting practices to make sure that the guidelines are being properly and effectively implemented; simply having these policies in place is not enough to ensure patient safety. 
  • Use objective measures to assess cleaning effectiveness. When conducted successfully, using a frequent and consistent approach, audits provide valuable information that can identify opportunities for quality improvement and track progress over time.
  • Use audits as an opportunity for improvement, not for punishment. 
  • Consider using the following popular, relatively easy-to-use tools to audit cleaning practices:
    • Fluorescent gel. Fluorescent gel is placed on a surface before cleaning. After cleaning is complete, a black light is used to illuminate whether or not the gel has been removed. 
    • ATP. The presence of ATP can indicate the presence of organic matter, such as C. difficile or C. difficile spores. ATP creates a bioluminescence, which is measured by a device called a luminometer. For surface contamination testing, the specific area is swabbed and inserted into the luminometer to measure the organic material. 
    • Base auditing frequency on the needs, resources and improvement goals of hospitals and/or units. However, auditing frequency must be risk-based (e.g., high-risk areas such as the operating room and bone marrow transplant/cancer unit will need more frequent auditing). Also, it is very important to make sure that all staff responsible for cleaning and disinfecting the environment are monitored at least annually. 
    • Provide feedback to staff on environmental cleaning and disinfecting practices in a timely, clear manner that is directed towards improvement rather than punishment.
    • Encourage the group or team atmosphere when providing feedback by using ‘we’ statements (e.g., how can ‘WE’ work together to improve CDI cleaning and disinfection?). Spend time listening to staff concerns, and refrain from placing blame.

Tools, Resources and Further Reading
Staff Empowerment
You indicated that staff are not empowered to speak up to remind colleagues to perform proper hand hygiene and use personal protective equipment (PPE). A key aspect of preventing CDI is preventing C. difficile transmission. Staff should be encouraged and empowered to remind colleagues about strict glove use, wearing proper PPE and performing hand hygiene. Consider using a facility-wide common reminder phrase to get everyone on the same page and keep reminders from feeling punitive; it’s about patient safety, not punishment.

A. Hand Hygiene and PPE Use Essentials for Preventing CDI
  • Implement a process for early detection of CDI to promptly place patients into Contact Precautions.
  • Promote strict glove use. Change gloves immediately if soiled, and remove gloves as well as other PPE used during patient care when leaving the patient room. 
  • Hand hygiene, using alcohol-based hand rub (ABHR) is the preferred method of hand hygiene in hospitals unless a hospital or unit has high endemic rates of CDI or hands are visibly soiled.
  • In hospitals or units with high endemic (baseline) rates of CDI, promote hand hygiene with soap and water because C. difficile spores are not killed by alcohol. 
  • Perform hand hygiene prior to donning and doffing gloves; glove use is not a replacement for hand hygiene. 
  • Incorporate hand hygiene procedures and techniques and PPE use into routine, competency-based training for all staff. 
  • Conduct regular hand hygiene audits to ensure staff are performing hand hygiene effectively.
  • Conduct regular PPE audits to ensure staff are correctly donning and doffing PPE. 

B. Strategies for Creating a Culture of Safety and Empowering Staff to Remind Colleagues 
Staff should be empowered to speak up and remind colleagues if they see something wrong in the hospital or a hospital unit; this should be part of a hospital’s or unit’s culture. However, culture can be difficult to change. Moving a hospital or unit from punitive environment to one that focuses on and emphasizes open communication can have a profound impact on patient care and health outcomes. In a just culture, people are encouraged to report problems rather than hide them so issues can be addressed and prevented. 
  • Use of Champions. Recruit champions from different hospital disciplines to help bring the initiative to various hospital peer groups and units. Champions can help spearhead the initiative, provide support and guidance and empower colleagues to voice concerns. They can also help be a voice for frontline staff, relating ideas, barriers or concerns to the CDI prevention team and leadership. 
  • Create mutual understanding, using a common strategy or language to provide and receive feedback. Provide staff with the tools to help them speak up when Contact Precaution procedures are not being followed or when anything happens that could impact patient safety. The TeamSTEPPS Module 3 Communication and Module 6 Mutual Support can assist you in devising a strategy that will work for your hospital.
  • Share stories to help highlight the impact CDI and other infections have on patients. Staff engagement can be fostered or enhanced if all health care personnel appreciate the true risk associated with CDI. Sharing stories will also help tap into individuals’ internal motivators (knowledge, attitudes, beliefs and values), which help to inspire human behavior.
  • Share infection prevention data with staff. Data transparency can help motivate and engage staff to continue prevention efforts. Consider sharing the days that the hospital or unit has gone without a CDI. Staff can use this information to remind colleagues that proper hand hygiene and proper PPE use will help them continue the hospital or unit’s success of days since the last infection.

Tools, Resources and Further Reading
Identifying a Team
​“For the change effort to be successful, a powerful group must lead the change; and members of that group must work together as a team. Key characteristics that must be represented on the team include power, leadership skills, credibility, communications ability, expertise, authority, analytical skills, and a sense of urgency.” (TeamSTEPPS® 2.0.)

You indicated that either you don’t have a team or work group or the one you have does not function well. A key aspect of implementing a CDI prevention initiative is to identify an implementation team at your site. This team plays a critical role in developing the initiative and assisting with implementation. Key responsibilities of this team are education, data collection and evaluation. Individuals can fill more than one role and some may be short-term and others longer-term. 

A. Suggested Team Membership
Team composition can be crucial to the success of the team. Individuals with different clinical expertise and levels of experience can provide unique perspective and insight, enhancing initiative implementation. The following are suggested members to include on the team: 
  • Team Leader: The team leader is responsible for coordinating CDI prevention efforts, integrating CDI prevention practices into daily workflow, and collaborating with the various initiative champions. When selecting a team leader, consider someone with leadership and management skills and previous successes in leading quality improvement. These attributes are more important than the job title or content expertise. For more information, see "Identifying a Team Leader" (below).
  • Nurse Champion: The nurse champion is responsible for engaging nursing staff in CDI prevention efforts and working to integrate practice into daily nursing workflow. When selecting a nurse champion, consider someone who is well respected and in a position to obtain support from other nurses. 
  • Physician Champion: The physician champion is responsible for engaging physicians in CDI prevention efforts and coordinating CDI prevention efforts that require physician support. When selecting a physician champion, consider someone who is highly regarded by his or her peers. The first choice should be a physician who is actively engaged in the process; however, if one is not available, consider a physician who is widely respected by their peers, even if they are only able to lend their name to the initiative as this will still be an asset. Physicians involved in antibiotic stewardship at their hospital or infectious diseases physicians would be ideal candidates. For more information, "Identifying a Physician Champion" (below). 
  • Pharmacist Champion: The pharmacist champion is responsible for engaging pharmacy staff and coordinating antibiotic stewardship efforts to prevent CDI. When selecting a pharmacist champion, consider someone who is passionate about CDI prevention and takes pride in providing excellent care. A pharmacist who has expertise in infectious diseases and antibiotic stewardship would be a particularly good choice.
  • Performance Improvement Leader: The performance improvement leader is responsible for providing expertise to the team on systematic formal approaches of performance improvement. Select someone in your organization with training and expertise in performance improvement strategies, data collection strategies, and sampling methods and who knows where key data in your organization resides, such as billing or coding data.
  • Infection Preventionist: This person will provide content expertise and will be heavily involved in developing prevention strategies, an educational plan, and a monitoring plan.
  • Data Champion: The data champion is a vital member of the team, so this person must be committed to the initiative. Collecting and monitoring the data are crucial components of preventing CDI. This person will work closely with the quality improvement leader, the infection preventionist and others to oversee and manage data collection, aggregation and reporting.
  • Microbiologist: This microbiologist will be essential to assist in understanding the facility’s C. difficile testing and impact of other diagnostics on antibiotic utilization. Familiarity with local C. difficile testing practices and specimen handling are necessary to understand how best to select a C. difficile diagnostic assay(s) for a facility and how to interpret that assay based on local practices. In addition, this team member can advise on more rapid diagnostic technologies; these technologies would shorten the time to identify microorganisms, allow for better targeting of antibiotic therapy and potentially reduce both unnecessary antibiotic exposures and time of optimal therapy. The microbiologist can also advise regarding best pre-analytical specimen processing protocols to ensure proper and timely specimen collection for needed diagnostics.
  • Environmental Services Champion: Effective environmental cleaning is a crucial part of preventing CDI transmission. The environmental services champion will garner buy-in and help integrate CDI prevention strategies into the environmental services daily workflow. Some hospitals have trouble getting environmental services involved in quality improvement efforts; using a champion and engaging them early will help bolster this partnership and lead to better coordination of environmental services and infection prevention efforts.
  • Other Persons to Consider Including: A senior leader, nurse educator, infectious diseases physician, finance expert, communications or electronic medical representative and a patient who has had CDI or their family member. 

This list is by no means exhaustive but provides the minimum recommended members. You should consider adding other individuals based on the culture of your institution. In addition, some team members may assume more than one role. For example, the quality improvement leader may also be the team leader. Dedicated time for the initiative for each member is ideal; however, if this is not possible, then consider having co-champions to lighten the workload and provide mutual support.
 
B. Team Expectations
  • The team must take ownership of the CDI prevention.
  • The team must meet on a regular basis; every other week is recommended in the beginning.
  • The team must implement the initiative, which will involve educating various health care staff, auditing practices and providing feedback to staff and leadership on implementation. 
  • The team must collect data on a regular basis and share it with staff. 

Tools, Resources and Further Reading
Identifying a Team Leader
​You indicated that either you do not have a team leader or that the one you have does not have appropriate time for the initiative. The team leader is responsible for coordinating CDI prevention efforts and integrating CDI prevention practices into daily workflow and collaborating with the various initiative champions. In other words, the details of the CDI prevention initiative fall to the team leader. It is his or her responsibility to keep the infection prevention efforts moving forward and coordinate the moving pieces. It is unlikely that the CDI prevention initiative is the only responsibility of the team leader, and because of this, there may not be enough time devoted to the prevention efforts. Creating that dedicated time is imperative to a successful initiative. The following are recommendations on how to ensure the success of the team leader.

A. If the team leader role needs to be filled, consider:
  • Asking senior leadership for advice about whom they recommend who can have some protected time to do this work. 
  • Finding someone who has been successful in coordinating other performance improvement initiatives. 
  • Reaching out to a staff person who is passionate about CDI prevention and may be motivated to be a part of this initiative.
  • Recruiting an individual with leadership skills, enthusiasm, persistence and credibility. Their experience and knowledge on CDI should be secondary; leaders can reach out to content experts for guidance related to the technical aspects of the work.

B. If the selected team leader is not as effective as necessary, then:
  • Check to see if the team leader has been given dedicated time to work on this particular initiative. If not, engage leadership to help ensure the team leader has enough dedicated time. 
  • Consider that the team leader may need coaching in communication, collaboration and other teamwork skills. Identify a coach or mentor for the team leader and engage that person to provide coaching on an ongoing basis.
  • In some instances, the team leader may not be a good fit for the initiative. Perhaps they were appointed rather than recruited, and a replacement should be considered. 

Tools, Resources and Further Reading
Identifying a Physician Champion
​You indicated that either you do not have a physician champion or that the one you have is not effective. The physician champion is responsible for engaging physicians in CDI prevention efforts and coordinating CDI prevention efforts that require physician support. A successful CDI prevention initiative requires collaboration and cooperation with physicians. A physician champion is needed to bring the initiative to the other physicians, to help engage them, to be a part of problem solving when there is resistance or another challenge from this group of providers, and to gain physician cooperation.

A. If the physician champion role needs to be filled, then:
  • Identify the type of physician who will work best in your organization. There is no “one-size-fits-all” strategy. Some suggestions include hospital epidemiologists, hospitalists, infectious diseases specialists and gastroenterologists. At teaching hospitals, residents or chief residents may also be good candidates. However, beware of choosing people based on their job title; unfortunately, titles do not guarantee an individual will be up to the task.
  • Recruit a physician champion who has pride in the hospital’s culture of excellence or concern over the lack of one. Ideally, this physician may have the ear of the hospital administration and the respect of their peers from the quality of their service and excellent patient care. They would be someone who has the patience to hear others’ views that may differ from their own. 
  • Temporarily relieve the physician champion of some responsibilities to give them time for CDI-related work. 
  • Assure physicians that their role will not take too much time. Physicians, especially those who are not hospital employees, may be resistant to the idea of taking on more work. Physician champions should not, for example, be expected to attend all meetings or be otherwise involved in matters unrelated to clinical concerns, unless of course they want to be. Their chief responsibility will be to share the details of the initiative with colleagues and gain their cooperation. 
  • Consider including the champion’s activities towards their obligations to meet credentialing requirements for the hospital. 
  • Consider using co-champions if other measures do not work as this can help to lighten the workload; however, this can also diffuse responsibility.
  • Consider ways to recognize and reward physicians, including: 
    • Recognizing a member of the medical staff with a “physician champion” award, complete with a certificate signed by the hospital’s chief of staff and a gift certificate to a local restaurant.
    • Providing financial compensation to physicians who actively participate in infection prevention initiatives as champions. 
 
B. If the physician champion on your team is not as effective or engaged as needed, then:
  • Use influencers, such as strong nurse-physician working relationships, to garner physician buy-in and support, especially if the new practice is viewed as a “nursing initiative.” However, since there are significant physician practice initiatives within CDI prevention work, such as antibiotic stewardship, having one or even two strong physician champions is essential.
  • Check to see if the physician champion has been given dedicated time to work on CDI prevention. If not, engage leadership to help with this.
  • In some instances, the physician champion is not a good fit for the initiative; perhaps they were appointed rather than recruited. Consider replacing the physician champion. 
  • Make sure that medical leadership supports the initiative. 
  • Find a member of the ‘tribe.’ Some physicians respond better and are more receptive to ideas from physicians within the same discipline. For example, surgeons may be more receptive to a new collaborative or protocol if you have another surgeon championing the initiative. For CDI prevention initiatives, consider recruiting a physician champion who is an infectious disease specialist, an internist, or hospitalist. However, it is important to keep in mind the culture of your hospital’s medical staff. Which individuals are thought leaders and are well-respected among their colleagues? These individuals will have more success at getting buy-in from resistant peers. 

Tools, Resources and Further Reading
Senior Leadership Support
​You indicated that you do not have the support of senior leadership. Given the many competing priorities of hospitals, having the support of leadership is key to making immediate and lasting progress with your CDI prevention initiative. Having a member of the hospital executive leadership team oversee the initiative lets the hospital staff know the importance of the initiative.

A. Strategies to Engaging Leadership
  • Understand senior leadership’s perspective and priorities and tailor what and how you communicate information about this initiative. Senior leaders are essential allies in securing resources, overcoming barriers and aligning organizational priorities for your CDI prevention activities. The American College of Healthcare Executives annual survey highlights that the top issues of immediate concern for hospital CEOs are: financial challenges, government mandates and patient safety and quality. (From Top Issues Confronting Hospital in 2016. American College of Healthcare Executives. 2016. Accessed July 12, 2017.)
  • Appreciate that different senior leaders may have different concerns about the initiative or hospital priorities. For example, the chief nursing officer may be concerned about nursing shortages and their impact on patient outcomes, while the finance executive may worry more about how to help keep costs down. By understanding what matters to the individual, you can more effectively tailor your communications, and your requests will be more likely to gain support.
  • Create a business case to help succinctly present your plan to leadership, ensure sufficient resources are available to sustain performance, summarize the goals and vision of the initiative, define how the organization will avoid errors and prepare for success, and connect your CDI prevention efforts with other safety initiatives and organizational performance. 
    • For more information on how to develop a business case, review the STRIVE Modules BC 101 and BC 102.
  • Share monthly data and high-level progress updates with leadership. Important data to share include: 
    • Number of patients with hospital-associated CDI 
    • Compliance with process measures, such as hand hygiene, environmental cleaning, stool testing, etc. 

B. Ways for Leaders to Show Support
  • Share information about the CDI prevention initiative in leadership and staff meetings and during staff encounters. Consider including initiative updates and successes in hospital-wide newsletters, patient and family information, and online communications. Make sure to emphasize that CDI prevention efforts reflects the hospital’s mission and values. 
  • Attend and listen to report-outs on CDI prevention efforts. This will help to boost the improvement team’s sense of purpose. 
  • Include staff engagement in infection prevention initiatives in hospital employee credentialing requirements.
  • Encourage supervisors to provide support and backing when the improvement team encounters roadblocks. 

Tools, Resources and Further Reading