title: Clostridium difficile infection incidence: impact of audit and feedback programme to improve room cleaning.
abstract: BACKGROUND
  Audit and feedback programmes (AFPs) using fluorescent marking lead to improvements in room cleaning but have not been linked to reduced Clostridium difficile infection (CDI) incidence.
  
  
  OBJECTIVE
  To evaluate the impact of an AFP on hospital-acquired CDI incidence.
  
  
  METHODS
  In 2012, a hospital-wide AFP was implemented. Fluorescent marking of high-touch surfaces was used to assess discharge cleaning thoroughness. Weekly audit results were presented to cleaning staff. Interrupted time-series analysis was used to test for changes in the trend and level of hospital-acquired CDI incidence between the pre-intervention (January 2008 to December 2011) and post-intervention (April 2012 to June 2015) periods.
  
  
  RESULTS
  In all, 1002 audits were performed and room cleaning thoroughness improved from 49% to 90%. Hospital-acquired CDI incidence fell from 54 to 42 cases per 100,000 patient-days following the intervention whereas non-hospital-acquired CDI incidence rose from 43 to 52 cases per 100,000 patient-days, although both exhibited a downward trend post intervention. Time-series analysis showed that hospital-acquired CDI incidence was declining at a rate of 0.59 cases per 100,000 patient-days per quarter before the intervention. Following programme implementation, the rate of decline accelerated by an additional 1.35 cases per 100,000 patient-days per quarter (P < 0.05). Hand hygiene compliance increased minimally post intervention.
  
  
  CONCLUSIONS
  Implementation of an AFP using fluorescent marking resulted in improved thoroughness of room cleaning and appeared to result in an enhanced downward trend in CDI incidence, although part of this decline could be due to changes in local CDI epidemiology or improved hand hygiene.
authors.affiliation: Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Smith
authors.affiliation: Department of Medicine, St Michael's Hospital, Toronto, Canada; Infection Prevention and Control Service, St Michael's Hospital, Toronto, Canada.
authors.forename: L R
authors.initials: LR
authors.lastname: Taggart
authors.affiliation: Applied Health Research Center, Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
authors.forename: G
authors.initials: G
authors.lastname: Lebovic
authors.affiliation: Environmental Services, St Michael's Hospital, Toronto, Canada.
authors.forename: N
authors.initials: N
authors.lastname: Zeynalova
authors.affiliation: Infection Prevention and Control Service, St Michael's Hospital, Toronto, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Khan
authors.affiliation: Department of Medicine, St Michael's Hospital, Toronto, Canada; Infection Prevention and Control Service, St Michael's Hospital, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. Electronic address: mullerm@smh.ca.
authors.forename: M P
authors.initials: MP
authors.lastname: Muller
mesh_terms: D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D003967:Diarrhea / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D005246:Feedback; D006302:Health Services Research; D006797:Housekeeping, Hospital / Q000379:methods*; D006801:Humans; D015994:Incidence; D017053:Infection Control / Q000379:methods*; D013194:Staining and Labeling / Q000379:methods
keywords: Audit and feedback; Clostridium difficile; Environmental cleaning; Healthcare-associated infection