Conquering C. difficile


New and old infection control techniques work together to conquer C. difficile

Ongoing staff education and new technology bring outbreak under control

A proactive approach by the infection prevention and control (IPAC) team at Rouge Valley Health System (RVHS) recently brought a Clostridium difficile (C. difficile) outbreak under control in less than two weeks.

C.difficile is a bacterium and a common cause of diarrhea in hospitalized patients. It can survive for up to five months in health care settings.

With the synergy of regular staff engagement on infection control principles, implementing syndromic surveillance at the unit level, and using ultraviolet microbial technology as adjunct to existing cleaning protocols, the ability to control this outbreak relied on both going back to basics and embracing the new.

Going back to basics started with IPAC launching “Infection Control 101” unit-based teaching modules in 2014 to refresh and update knowledge for all staff.  Module topics included chain of transmission, personal protective equipment, routine practices and hand hygiene, and additional precautions.


“Infection Control 101 supports a culture in which staff are thinking about infection control on a regular basis,” says Paula Raggiunti, director, quality & infection prevention & control at RVHS. “The front line is engaged with infection control. It moves us from being reactive to proactive,” she adds.

The pilot unit for Infection Control 101 was 2 North (a continuing care unit) at the Rouge Valley Ajax and Pickering (RVAP) hospital campus. IPAC brought their 15-minute PowerPoint presentations to the unit during a weekly set time that was convenient for unit staff. So far, these staff have completed four modules of the 12 planned. Gradually, IPAC has introduced these modules on other units at both RVAP and the Rouge Valley Centenary (RVC) hospital campus.

“It’s like building a house,” says Bryan Morales, infection control practitioner (ICP) at RVAP. “We pour the foundation of infection control practices by first teaching about the chain of transmission.”

Adding to a regular and standardized infection control curriculum, IPAC has piloted and implemented a syndromic surveillance program on several units cross-site, including 2 North. Syndromic surveillance is a system of monitoring a group of patients on a unit for specific signs and symptoms of gastroenteric or respiratory illness. At the beginning and end of every shift, the charge nurse asks the nursing staff if there are any patients with new fever, cough, shortness of breath, vomiting or diarrhea. This has three benefits: accurate early reporting of these symptoms allows staff and IPAC to determine when a patient needs to be placed on additional precautions; it assists IPAC to determine if the unit is on outbreak; and it supports staff to intervene for patient care in a timely way.


At Rouge Valley, syndromic surveillance has been strengthened with the participation of the unit staff. “Before syndromic surveillance was implemented, a patient could be tested for C. difficile but it wasn’t always reported to IPAC,” says Amanda Whyte, registered nurse and one of the unit coordinators on 2 North. “IPAC wouldn’t hear about it until they were faxed a positive result. Now, we inform them right away,” she adds.

Between Nov. 6 and 20 of 2014, there was a C. difficile outbreak on 2 North. Staff informed IPAC of the first suspected case immediately.

With an outbreak, rooms require additional cleaning with sporicidal agents such as bleach.  Janette Henderson, support services manager at Rouge Valley, suggested using a new supplemental cleaning technology: a surface and air decontamination tool that delivers ultraviolet germicidal irradiation (UVGI) to all surfaces of a targeted space. Henderson had already overseen the use of this method for terminal cleaning in the operating rooms at both hospital campuses. UVGI works particularly well on killing C. difficile spores.

“UVGI does not replace terminal cleaning but supplements it,” says Henderson.


The outbreak lasted only two weeks, with no new cases after the initial three. “In this case on 2 North, early and aggressive intervention, including identification of cases, IPAC countermeasures, and close cooperation between IPAC, and clinical and environmental staff and managers were key to successful containment,” says Michael Paetzold, ICP at RVAP and the lead investigator of the outbreak.

Next, IPAC will be launching the rest of their back-to-basics modules in 2015. They will continue embracing the new, as they will be filming the modules and archiving them via the Ontario Telemedicine Network (OTN).

Rouge Valley is also a member of the emergency department syndromic surveillance (EDSS) collaborative maintained and operated by Kingston, Frontenac and Lennox & Addington (KFL&A) Public Health unit. This provides the hospital with an overview of how many ED patients are presenting with respiratory or gastroenteric symptoms to monitor trends that may be developing.