Diagnostic testing

Only in the physician and nurse focus groups was the diagnostic testing subprocess discussed. Physicians described person-related barriers to identifying CDI that included synthesizing information from patients presenting with multiple complicated conditions (Q1). For trainee physicians, recognizing when to suspect CDI versus antibiotic-associated diarrhea alone was a challenge. Trainee physicians also reported that peer influence sometimes results in either over-ordering tests to avoid embarrassment for missing the diagnosis, or under-ordering tests to avoid unnecessary precautions if CDI is not confirmed (Q2). Nurses identified challenges in recognizing the need to order a diagnostic test because they perceived that patients do not want to be “embarrassed” or “bother” the nurse to discuss their diarrhea (Q3). Physicians and nurses concurred regarding barriers associated with obtaining an accurate history or appropriately identifying signs of CDI. Only nurses described facilitators associated with the person element; it related to their clinical experience and ability to recognize CDI based on odor and appearance of the stool sample (Q4).

Physicians reported barriers associated with the electronic health record (EHR; ie, a technology) including inconsistent location and documentation of symptoms and signs. Another barrier was that EHR alerts or flags that inform clinicians of a patient’s recent CDI diagnosis are automatically removed 90 days after CDI diagnosis. Physicians also described overuse of e-mail to clinicians, which is less efficient than the EHR in conveying CDI-related (and other) policies and procedures. They also identified design aspects of the EHR that facilitate information finding, and both the physicians and nurses reported that EHR design made it easy to place orders (Q5).

Physicians described organization barriers such as inadequate information when patients are transferred from other healthcare facilities. Nurses reported that inconsistent practices for CDI patients across units is a barrier in caring for these patients (Q6). Other organization barriers identified by both nurses and physicians were related to poor communication between different roles caring for CDI patients and at the handoff between shifts. Physicians reported that nurses’ ability to place orders for diagnostic tests when they suspect CDI facilitated patient care by expediting the diagnostic process. Both focus groups described an organization facilitator: a heightened awareness by clinical staff of CDI (Q7) and the responsiveness of other services (eg, the laboratory) to test or for information requests regarding CDI.

Empiric isolation

Person-related barriers unique to physicians included the belief that CDI is not foremost on a physician’s mind when taking a patient’s history and conducting a physical examination. In addition, physicians reported variation among physicians regarding ordering practices for C. difficile testing because these physicians may be uncertain of CDI- versus antibiotic-associated diarrhea (Q8). Physicians and nurses noted that patients with suspected CDI sometimes become overwhelmed by and may not understand why healthcare workers must take isolation precautions (Q9). Physicians confirmed that taking precautions (eg, donning gowns and gloves) slows down rounds (ie, a task barrier), although the ability to give verbal orders expedites (ie, facilitates) their work (10).

Physicians listed barriers related to technology use including difficulty getting access to a computer, resulting in delays in writing orders. Physicians reported that an isolation order is automatically generated when placing a diagnostic test order and that this feature facilitates the process of empiric isolation.

Nurses reported that receiving incomplete patient information upon transfer from the emergency department was an organization barrier. Physicians identified nurses’ ability to place a diagnostic test order independent of the physician as an organization facilitator (Q11). In the facility where this study was conducted, nurses could place laboratory orders to test for CDI within the first 72 hours of patient admission if there was high suspicion of CDI based on clinical findings such as diarrhea or patient history such as recent antibiotic therapy. In addition, nurses reported that all patient rooms (physical environment) are isolation-eligible. This was another facilitator to executing empiric isolation.

Contact isolation

Both physicians and nurses discussed negative consequences (ie, barriers) associated with a lack of knowledge or awareness regarding CDI. For example, physicians reported hearing conflicting evidence concerning contact isolation procedures (Q12), and nurses discussed instances when care team members, despite entering a patient’s room, did not follow contact isolation procedures because they did not have direct physical contact with the patient or items in the patient’s room (Q13). Both groups discussed negative consequences of delays in posting isolation signs. In addition, both groups talked about patients’ negative reaction to everyone entering their room wearing gowns and gloves (Q9).

All 3 groups (physicians, nurses, and EVS staff) described the increased workload (task barriers) associated with contact isolation. Physicians described slower rounds, EVS staff described additional handwashing procedures, and nurses identified both issues. Nurses and physicians described delays in stocking necessary supplies for CDI patients, thus delaying or extending rounds. EVS staff described increased workload and lost time when, to facilitate access to a patient by the healthcare team, they must leave a patient room (and return later) so the team can efficiently complete rounds (Q14). In this case, expedited access to the patient by the healthcare team (a facilitator) conflicts with effective room cleaning by EVS staff. Task-related facilitators identified by nurses included using slow periods to ensure adequate stocking of contact isolation supplies.

EVS staff reported that, occasionally, non-EVS staff prematurely remove signs prior to cleaning a discharged CDI patient’s room, which presents a barrier to contact isolation compliance. Physicians reported that taking other tools and technologies (eg, computers, food trays, pagers) into a patient room poses potential for colonization of this equipment by C. difficile. Nurses reported that it was challenging to put on gloves immediately after washing their hands. EVS staff and physicians explained how “excessive” sign use sometimes caused them to overlook contact isolation precaution signs (Q15). Nurses and physicians reported that they sometimes run out of supplies (eg, gowns) needed to comply with contact precautions. All 3 focus groups discussed a common barrier of feeling overly warm when wearing gowns. Tool-related facilitators discussed by EVS and physician focus groups included benefits of “appropriate” sign use to ensure precaution compliance. Nurses and EVS staff identified strategies that facilitate their work, including the use of pagers by supervisors to ensure staff awareness of CDI patient rooms. Nurses described using larger carts to meet the additional supply demands of CDI patients.

Each focus group identified different organizational barriers. EVS staff discussed the negative consequences of significant staff turnover and consequent training needs (Q16). Physicians talked about pressure from peers to not over-order diagnostic tests, and nurses described confusion due to constantly changing CDI policies (Q17). Physicians noted that clinical team member assistance, such as a recommendation by an experienced nurse, facilitates CDI procedure compliance. Nurses spoke positively about the organization’s policy that considers CDI patient volume when assigning nurse-to-patient ratios.

From a physical environment perspective, EVS staff noted that seeing a bag of gowns outside a patient room is a visual cue to follow contact isolation precautions (ie, a facilitator), and physicians stated that supply cabinets provide a common location for storing gowns.

Hand hygiene

Nurses and physicians reported a lack of common awareness regarding when hand hygiene and glove use should be practiced when caring for a patient with suspected or confirmed CDI (Q18). They also reported breakdowns in compliance with contact precautions that result when other staff fail to post isolation precautions signs (Q19). All of these are person-related barriers. EVS staff reported that having to perform hand hygiene multiple times for a single room (a task barrier) increases workload.

Participants from all 3 focus groups reported difficulty putting on gloves immediately after applying hand hygiene gel (Q20). Physicians and nurses talked about inconsistency of door sign content, and nurses pointed out the drying effect of excessive hand hygiene. All of these are tool-related barriers. EVS staff commented positively on signs noting CDI rooms. Physicians and EVS staff stated that soap is always available. Facilitators also included strategies by nurses and EVS staff to use larger size gloves after applying hand hygiene gel. All 3 groups reported that signs placed on gel dispensers provide clear hand hygiene instructions.

EVS staff and physicians identified several organizational barriers to hand hygiene. EVS staff reported the impact of high staff turnover on hand hygiene awareness and time pressure associated with having to leave a patient’s room at a physician’s request without performing proper hand hygiene (Q21). Physicians reported inconsistent understanding of where to perform hand hygiene (Q22) and problems resulting when all team members are not present in a CDI patient’s room during rounds. An organizational facilitator noted by the physicians was the support interns receive from nurses. Nurses talked about peer support for monitoring CDI patients.

Nurses also described physical environment barriers associated with patients trying to access the soap dispenser and the lack of foot pedals on sinks in patient rooms. Foot pedals on hallway sinks facilitated hand washing without contamination of the sink by hands. Common barriers associated with sink use were identified by all 3 focus groups, including challenges accessing the sinks due to their location, the number of sinks on a unit, and clutter interfering with access to sinks.

Disinfection

Nurses reported that keeping the supply cabinets organized and clean was a challenge due to the large number of people who access it (Q23). EVS staff stated that patients preferred the smell of the current room cleaner (Oxycide) compared to bleach used previously.

All task barriers were identified during the EVS focus group and related to the timing and special requirements associated with disinfection of CDI patient rooms. Workflow is negatively affected when EVS staff receive “stat” or urgent requests to clean a room immediately (Q24). Workflow is also affected when clinicians wish to enter a patient room during disinfection. EVS staff perceive that the convenience afforded to clinicians supersedes EVS staff work. Finally, needing to change curtains in a patient room adversely affects workflow (Q25), as does patients being on multiple external devices and lines. EVS personnel generally do not handle such equipment, yet they have to clean around it.

EVS staff identified barriers to tool and technology availability for rooms of discharged patients, including delayed access to disinfection machines and premature removal of isolation signs posted on patient doors (Q26). Physicians noted that it is challenging to determine whether disinfection is necessary for tools and instruments such as pens, computers, pagers, and stethoscopes. Nurses talked about medications taken into a patient room that, if not used, must be disposed of outside the room because they cannot be disinfected. Each focus group identified a single tool or technology that facilitated room disinfection (Q27).

EVS staff talked extensively about organizational barriers associated with high staff turnover, training, scheduling, and work expectations by supervisors and clinicians. Nurses discussed having an inadequate understanding of disinfection techniques and organizational decisions, resulting in an insufficient number of medication scanners, which frequently compromises appropriate use. EVS staff and nurses also discussed a lack of clarity regarding their respective responsibilities in disinfection. Physicians reported that they place pressure on EVS staff to expeditiously clean a discharged CDI patient’s room to facilitate a new admission despite the potentially negative consequence of rushed room disinfection (Q28). Although rushed cleaning may compromise disinfection, physicians commonly request “stat” cleaning, which introduces conflicting goals between physicians and EVS staff.

Elements of the physical environment pose barriers to EVS staff trying to adequately disinfect CDI patients’ rooms, such as when clean curtains are not available or when patient’s personal supplies clutter the room. Nurses were unsure of which aspects of the physical environment need to be disinfected (eg, white boards). They also viewed excessive equipment and furniture in the room as interfering with the disinfection process. EVS staff discussed the positive presence of bags of gowns, which helps them anticipate a CDI patient’s room.