Healthcare failure mode and effect analysis (HFMEA) approach to the control of healthcare-associated Clostridium difficile in system wide acute and long-term care facilities

ISSUE: Clostridium difficile (C. difficile), the most common cause of healthcare-associated diarrhea, can live for months on environmental surfaces. Our health system, with a combined 679 beds in two acute care hospitals and four long-term facilities, noted an increased incidence of healthcare-associated C. difficile in early 2004. We set out to lower the number of occurrences by using the HFMEA process. PROJECT: Regular surveillance of healthcare-associated C. difficile determined there was an increased rate of incidence between one acute care hospital and the corresponding nursing home. A task force with representation from the involved clinical units, environmental services, and infection control was developed to address the issues using the HFMEA approach. Specific causes of the transmission of this pathogen were grouped into failures in communication, cleaning procedures and compliance to isolation/precaution procedures, and hand hygiene. Corrective actions included: 1) comprehensive education on C. difficile for clinical and environmental services; 2) coordination between nursing and environmental services on proper procedures for terminal cleaning rooms; 3) new signage and letters for patients/residents and families illustrating proper precaution procedures; 4) implementation of nursing competencies on isolation procedures; 5) a systemwide equipment cleaning procedure, and 6) a method of labeling known or suspect C. difficile patient/resident equipment with color specific name bracelets. RESULTS: Improvement was seen in the surveillance data. The incidence of systemwide combined acute and long-term care cases of healthcare-associated C. difficile decreased from 24 in the first quarter to 4 in the last quarter of 2004. The rate per 100 patient census days in the applicable acute care went from 0.27 in the first quarter to 0.06 in the last quarter of 2004. LESSONS LEARNED: It takes many individuals and departments in hospitals and nursing homes to deliver healthcare today. A team effort is needed to correct issues that cross departments. Working staff can bring valuable information to a multidisciplinary task force addressing a concern. The HFMEA approach to corrective action is comprehensive and effective. Aligning the probability of frequency of occurrence with severity of the effect of the failure determines the priorities of the corrective actions.