My Personal Leadership Experience

The Problem

The identified problem related to practice is the spread of Clostridium difficile in the Emergency Department. Clostridium difficile (C. difficile) is a prevalent problem as it occurs after patients in the ED use antibiotics or after being exposed overnight to the ED environment (McDonald, Kutty & Kaplan, 2017). According to a nationwide U.S inpatient database, there has been an increase of C. difficile Infections by more than 43% since 2001 (Davies et al., 2014).

This problem is related to my area of practice in the emergency department and the healthcare field given that C.

difficile infections are very challenging to control. Despite the increased surveillance strategies instituted by the Centre for Disease Control and Prevention (CDC), there were 862 incident cases of C. difficile reported in 2017 (McDonald, Kutty & Kaplan, 2017). C. difficile marks as the leading cause of healthcare related gastrointestinal illness and weighs heavily on the United States healthcare system leading to over 14,000 casualties. It is also associated with a financial burden of over $ 2.1 billion on an annual scale (Davies et al., 2014). In essence, the level of C. difficile is endemic in healthcare organizations and is highly associated with previous utilization of antibiotics. Conclusively, while the use of antibiotics in the ED and exposure to the ED environment is associated with increased cases of C. difficile, there are other cases that occur beyond the traditional healthcare settings that are community-associated (van Dorp et al., 2016). It is established that 62% of the cases are classified as Community Associated with 18% categorized under Community-Onset Health Facility Onset (McDonald, Kutty & Kaplan, 2017).

The Investigation

In the investigation phase of this project, numerous research, as well as non-research sources, were reviewed. Primarily, peer-reviewed journals from PubMed, Journal of Infection and Public Health as well as the Journal of International Medical Research. More significantly, documents and reports released by the CDC were more helpful in reviewing the statistics related to the prevalence of C. difficile. Also, getting insights from the Medical Operations Supervisors, the Assistant Manager, and the Registered Nurses at the ED of the healthcare facility where I work was extensively helpful and led to a meaningful revelation.

From these sources, it was affirmed that the spread of C. difficile has proved difficult to interrupt given that the patents who are affected in the Emergency Department release large volumes of spores that are then found in several surfaces of the patient rooms and are often transmitted through outside the rooms as fomites on the equipment used by providers (Davies et al., 2014).

Evidence Collected

The research and non-research sources showed that there has been an increase of incidents related to C. difficile, as well as mortality rate in the clinical settings across regions beyond the nation's geographical borders over the last decade. The reports from the CDC revealed that C. difficile has taken Methicillin-Resistant Staphylococcus Aureus' place and now marks as the leading healthcare-associated infection in the United States (McDonald, Kutty & Kaplan, 2017). Moreover, the rated of hospitals discharges with C. difficile as the diagnosis showed an increase from 3.82 to 8.75 per 1,000 discharged over a decade (Davies et al., 2014).

The spread of C. difficile in the Emergency Department have led to increased cases among individuals aged 65 and above (McDonald, Kutty & Kaplan, 2017). Preliminary research sources that reviewed the United States vital records showed that the rate of death certificates with enterocolitis caused by C. difficile marked as the leading cause of death among the geriatric population brought to the ED. While there has been a slight reduction of cases of death related to the spread of C. difficile, the age-related death rate of C. difficile rose from 2.0 deaths among 100, 000 populations to 2.3 deaths among 100, 000 population of 100, 0000 (Lessa et al., 2015). The revelation of this endemic issue calls for the need to institute surveillance systems to review as well as monitor the trends of this infection and identify public health actions.

Current findings of the Spread of C. difficile in the ED

While preliminary studies show the prevalence of the infection in clinical facilities, current data findings show the definite status of the problem. Current research still shows that C. difficile is the most common healthcare related infection. It is revealed that in 2015, over 55.7 inpatients were treated with antibiotics, which led to an increase in new cases by 30% (Evans & Safdar, 2015). Moreover, it is established that there are 453,000 new cases of C. difficile and 83,000 recurrences as well as 29,300 deaths every year (Davies et al., 2014). According to the CDC (2014), C. difficile marks as an imminent threat given that 65.8% of new onsets are healthcare related and only 24.2% of patients infected experience symptoms before being discharged. Conclusively, van Dorp et al., (2016) reveals that the rate of reinfections and recurrence of the infection ranks at 40% despite the significant strides made in developing preventive measures.

Contributing Factors

There are several aspects leading to the spread of C. difficile in the ED. One of the factors is the proximity to patients with C. difficile given that the infection is airborne. Moreover, older patients are prone to severe chronic and comorbid conditions and often make more visits to the ED compared to other age groups further making them vulnerable to such infections (CDC, 2012). Lack of proper hygiene and improper management of equipment in the ED is also associated with the spread of the infection. Davies et al., (2014) showed that hospital-acquired infection can spread outside the ED as well as the hospital through food and drinks further increasing the incidents of new onsets.

Moreover, it was established that asymptomatic carriers of toxigenic C. difficile brought into the ED bear the imminent risk of infecting other patients in the ED and the clinical setting which explains the sluggish reduction rates of C. difficile infections and associated mortality rate. Van Dorp et al., (2016) add that patients presented to the ED with a history of using commonly prescribed heartburn medication are correlated to high rates of C. difficile. Conclusively, in a study conducted by Smits et al., (2016), it was established that patients with greater body mass index exceeding 35 kg/m2 are associated with increased cases of C. difficile (Longtin et al., 2017). For this reason, creating surveillance and preventive measures ought to be based on these current findings thereby ensuring that new onsets are mitigated and the infection controlled efficiently.

Proposed Solution

Currently, most of the preventive measures for C. difficile are used after patients become symptomatic. However, preventing the spread of this endemic infection ought to be based on early prevention efforts that mitigate the onset of adverse symptoms. Among the proposed solution is educating care providers how to identify patients at a high risk of being infected such as elderly patients, patients prescribed with antibiotics, as well as those prescribed with common heartburn medication (Longtin et al., 2017). This measure should be integrated with the establishment of a system for early reporting of patients with C. difficile symptoms to the clinical facility’s infection control delegate to ensure that the spread of the infection is mitigated.

Moreover, it would be imperative to provide training and educational programs to the staff tasked with environmental cleaning. This measure should be integrated with evaluating policies, procedures, practices as well as audits evaluate the efficacy of their cleaning practices (CDC, 2014). The ED should also contain policies and procedures that outline the responsibilities and tasks for disinfecting and cleaning items for ED patients including intravenous poles and multi-use electronics (Collignon et al., 2016). Finally, given that patients in the ED are often examining room with more than one patient, it would be imperative to ensure that patients with C. difficile are examined in a single room with that has a dedicated toilet.

The rationale for Proposed Solution

Providing education and training to care providers in the ED is essential given that prior preventive approaches focus on asymptomatic patients. For this reason, educating them on how to identify patients with C. difficile early would go an extra mile towards mitigating the spread of the infection as well as decreasing deaths associated with the infection among geriatric patients. Integrating this approach with the development of a system for early reporting of patients with C. difficile symptoms to the clinical facility’s infection control delegate is imperative as has been established that the age-related death rate tied C. difficile rose from 2.0 deaths among 100, 000 populations to 2.3 deaths among a population of 100, 000 (CDC, 2014).

On the other hand, educating and training staff responsible for cleaning and disinfecting is imperative as patients with C. difficile release large volumes of spores that are then found in several surfaces of the room and are often transmitted to other patients through fomites on the equipment used by staff. Developing policies and procedures outlining tasks and responsibilities would go an extra mile towards establishing adherence and discipline among those responsible for cleaning and disinfecting (Collignon et al., 2016). Conclusively, examining patients separately in a single room is also an essential approach following the fact that the infection is airborne and the spores released by patients with the infection may be transmitted to other patients.

Resources to Implement the Proposed Solution and Cost-Benefit Analysis

The implementation of the proposed solution requires additional resources. Primarily, it would be imperative to acquire audio, video as well as print materials. These materials would go an extra mile towards facilitating the education and training programs. With the resources, control charts would be created to displays the rates and cases of C. difficile that have been recorded in the healthcare facility over the past 5 years thereby determining the trends and how they can be addressed with early surveillance (Anderson et al., 2017).

Moreover, with the video and print materials would be used to create presentations on the effective cleaning and disinfecting routines and methods for staff responsible for environmental cleaning and disinfecting. An educator for educating the nurses and those responsible for environmental cleaning and disinfecting will also be required. Despite the costs that will be associated with these materials, the end result will put the healthcare organization in a competitive position.

Primarily, the strategy will lead to the prompt detection of high-risk patients and decrease the spread of the infection to other patients (Collignon et al., 2016). Moreover, it will lead to the prompt treatment of patients with C. difficile further increasing patient safety and quality. The increased patient safety and satisfaction will reflect positively on the organization’s image and improve its reputation (Ford II et al.., 2018). As a result., the healthcare facility would have an increased patient influx as well as decreased costs correlated to the treatment and diagnosis of C. difficile.

A Timeline for Implementation

In the first week would include orientation, where the clinical staff operating in the ED would be brought up to speed on what was about to take place. Moreover, current practices would be evaluated as well as current practices that may be leading to increased rates of C. difficile. The second week would entail engaging relevant stakeholders to support the implementation of the changes. Moreover, formal teams of healthcare providers and the staff responsible for cleaning and disinfecting would be created. On the other hand, the third week would entail critically appraising, evaluating and synthesizing evidence.

Moreover, this week would also entail assessing and eliminating probable barriers to implementation. The fourth and fifth week would entail establishing reporting procedures for symptomatic patients and developing procedures for tasks and responsibilities for cleaning and disinfecting. The sixth week would entail training and educating the teams. The seventh week will include requesting approval to implement the new practice and processes and implementing them. Conclusively, the performance evaluation and refining of the practice and process would be a continuous process.

Key Stakeholders

It would be imperative to derive that the implementation of the new practice process and procedures for mitigating the spread of C. difficile is dependent on the buy-in of the ED healthcare staff. More precisely the management, including the chief medical officer (CMO), Clinical Nurse Manager, Clinical Operations Manager, Assistant Manager, the Chief Financial Officer as well as a representative of the county health department. These stakeholders would go an extra mile towards contributing to the completion of the change process. Primarily, they would encourage the clinical staff in the ED to take part in ensuring that the implementation process runs smoothly. Moreover, they will play a very integral role in ensuring that the shareholders and board members of the organization have a full scope of the problem and approve the operations to address it. They will also aid in the development of effective C. difficile cases’ reporting strategies as well as the creating policies and procedures for cleaning and disinfecting (Guinn et al., 2016).

As key stakeholders in the leadership position, they will be influential in gaining the support of relevant ED members while emphasizing on the significance of implementing the intervention. Lastly, communication plays a very integral role in ensuring a transition runs smoothly. For this reason, these leaders would ensure that the channels of communication stay open among key stakeholders thereby compelling them to give their input on role development, voice their concerns as well as take part in reinforcing the accomplishment of major objectives (Ford II et al.., 2018).

The Chief Medical Officer and the Clinical Nurse Manager are among the key stakeholders who will help in the planning stage of the intervention implementation. This is because they oversee the authorization of relevant resources that would be employed during education. On the other hand, the Chief Financial Officer would oversee the budgeting and allocation of the training and education resources while the Assistant Manager will aid in fine-tuning the proposal before submitting to the board members for review for approval. The other leaders would help in the development of processes and procedures as well as influencing the key ED staff members to embrace the intervention.

How the Proposed Solution could be Implemented and Measured

After the current practices of preventing the spread of C. difficile have been reviewed, a team of nurses responsible for surveilling, diagnosing and treating patients and healthcare staff members responsible for cleaning and disinfecting the ED environment would be formed. They would be trained and educated by the educator and brought up to speed about the new policies and procedures for preventing the spread of C. difficile. With comprehensive training and education of the clinical staff members, the management would introduce the new practice policies after the chair of the board approves the interventions.

On the other hand, the success of the interventions will be evaluated by several possible metrics. Primarily, the rates of patients infected with C. difficile in the ED within the first month of implementation (Ford II et al.., 2018). Then the rate of deaths related to C. difficile among patients who visited the ED within the first six months since implementation. An analytical model would also be used to assess the cost-effectiveness and success of the intervention given that C. difficile is a recurrent infection that has proven to be challenging to mitigate over the past decade (World Health Organization, 2015). Conclusively, increased patients’ influx as a result of improved patient safety and quality care.

Explanation of Roles

Throughout the investigation and proposal project, I have assumed different roles that have guided the completion of this project. Primarily, I achieved my role as a scientist by employing evidence-based research and practices to establish that the spread of C. difficile in the ED is an endemic problem that requires prompt interventions. I achieved this through the developing scientific inquiries that were geared towards creating clinical decisions as well as through collecting and analyzing data correlated to C. difficile infection risk factors, detection and prevention measures based on evidence-based practices and research.

My role as a detective was achieved by exploring and surveying the healthcare staff working in the ED to identify the possible factors leading to the spread of the infection among patients in the ED. Conclusively, my role as a manager of the healing environment was achieved through the development, coordination as well as empowering others to learn and increase prevention awareness of C. difficile infection to unsuspecting individuals thereby increasing human dignity and welfare.

Consequently, through the development of a well-thought-out intervention with the ability to improve patient safety as well as quality care while encouraging key stakeholders to take part in the development process, my role as a manager was attained. 

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