Meeting the Quota on C.Diff

What is it with docs and ordering C.Diff?  Why is it that if a patient has diarrhea, the order a test for C.Diff?  Some days it feels like they went to an in-service recently and all remembered that C.Diff causes diarrhea and now anyone with loose stool should be checked -even if there are no other reasons besides loose stools.  Here are some great examples of stupid rule-outs for C.Diff.

Dude who has ruled out 5 times within the last 3 months, ruled out the previous week on Friday and now on Monday they decide think that he needs to be ruled out again.  Why?  His white count is up.  Did they forget that he has pretty much chronic aspiration pneumonia?  Guess what?  He ruled out a second time.

How about end-stage liver disease chick on lactulose?  We all know lactulose, right?  Binds to ammonia and flushes it out of the system – in the stool.  And it’s always diarrhea.  Never met a lactuloser with normal, non-runny poop.  “But by God, she might have C.Diff!  She has loose stools!” say the residents.  “What are you stupid?” say the nurses.  Guess who was right?

Or the LOL on tube feeds with no real gut flora anymore who has loose stools.  Or the liver resection dude that ruled out last week and evidently needs to be ruled out again.  Or the ICU transfer with colitis?  (OK, I’ll give ’em that one)  How about the LOL in with constipation who we give docusate, senna, biscoadyl, Miralax and MOM to so that they can poop, and when they do, thanks to all the loosening products that stool is nearly liquid?  They surely have the Diff, right?  Or my tried and true favorite, the patient who had 1 loose stool 5 days ago, and has yet to poop this admission.  They must have C.Diff.  But the patient so that is so bound up from narcs that they are pooping marbles, yes, the poop rattled in specimen cup just like a marble, pretty much takes the cake.

It almost like each resident group has a quota to fill for C.Diff rule-outs.  And even when presented with rational evidence like lactulose, multiple bowel care products, rules-outs less that 72 hours prior, they blunder on blustering about antibiotics and gut flora and elevated white counts and diarrhea.  Then they walk into the room without isolation gear on.  I don’t get it.

Funny Lookin’

We had just isolated a patient as it seemed they had C.Diff.  How did we know before we even sent a sample?  We’re nurses and rely heavily on the “deck method.”  Y’know, if it looks like a duck, acts like a duck and quacks like a duck, it’s probably a duck.  Translating that into poop, if it looks like the Diff, smells like the Diff and the patient is developing SIRS with a white count of nearly 20, we’re gonna’ guess it’s the Diff.  Lab tests?  Who needs that?  Nurses’ noses show and unbelievable 95% sensitivity and 98% specificity with diagnosing C.Diff.  But I digress…

So in isolation we gown up in the ever-fashionable yellow splatter-proof gowns, gloves and sometimes masks with just a touch of wintergreen oil to care for the patients.  The patient who was isolation thought we were just the funniest thing since Jerry Lewis.  As we walked in she looked up and giggled, “You guys look silly!”

From the mouths our elders…

It’s a Duck

You know the saying, if it looks like a duck, acts like a duck, quacks like a duck, it’s probably a duck.  I apply this to C.Diff.  If it looks like it, smells like it, comes as frequently as it, it probably is the Diff.  Simple right?  But what I never understand is the thought processes our highly trained resident physicians contort themselves through to diagnose the Diff.  Like I’ve said before, it seems like they have a quota to fill for C.Diff tests in a month and even if the evidence is such that the odds are pretty fucking low that it is the Diff, they’ll order it anyway, along with the resulting isolation.

Here’s what I mean.  Patient has been on antibiotics for a couple of days, notes cramping in their lower abdomen.  Mr. Resident orders stool for C.Diff thereby initating the cascade of events including moving the patient to a private room.  So what’s the problem?  The patient isn’t pooping.  Nothing.  Not a drop.  Usually with C.Diff they’re like a salad shooter, spraying infectious diarrhea across the room (OK, I’m exagerating…kind of).  Not them.  They’re constipated.  So the doc orders a suppository.  Just to get a sample.

Does this seem strange?  I know there are times when the Diff doesn’t cause CDAD, but more times than not, it ain’t the case.  It’s become my favorite order, a suppository for stool sample to screen for C.Diff.  When does it stop?

Aerial C.Diff?

Another entry into the “Holy shit!” files of scary drugs, diseases and conditions, add aerial C.Diff.  In this article: Aerial Dissemination of Clostridium difficile spores.

Adding airborne transmission to the standard contact transmission just increases the pucker factor.  The article goes on to note that aerial spores were captured on several tests showing samples of C.Diff in wards where there had not been active cases of C.Diff for weeks.  The authors postulate that this could be an explanation for the sporadic cases of CDAD (Clostridiun difficile associated diarrhea) that spring up seemingly out of nowhere.

While not surprising, it is enough to knock you back a bit.  Operating on the idea that it is solely contact based transmission has been the basis for everything we do when treating CDAD.  From terminal cleaning of the room post occupancy of a C.Diff patient to the gown and glove isolation we practice may not be enough to combat spread around a unit.

Combine aerial transmission with the over-abudance of PPI use (which studies have shown to be a  factor in C.Diff infection due to the breaking of the gastric acid barrier protection from reduced gastic pH) in a population already at risk of CDAD and you have a poop-strewn nightmare ready to happen.  While the article does not definitively note any cases where areial transmission is the sole cause of CDAD, it raises the specter that it proably does happen and that we need to adjust the way we protect our patients.  Terminal cleaning with bleach is one step, espeically for surface cleaning, but the cleaning of air remains another aspect all together that could require extensive revamping of HVAC systems hospital wide.

It’s hard to guage the true impact of this and the fallout it may have on protocols, but it could go some way to explain a lot of cases of CDAD.  Still it scares the poop out of me!

Dear Doctor – Again

Dear Doctor Single-minded,

I know that my patient’s chief complaint is C. Difficile colitis, but are you perhaps forgetting his rather substantial cardiac history? The fact he has coronary artery disease, congestive heart failure, has had both an MI and open heart surgery? I realize that his renal function stunk when he was admitted, but do you think it was all that wise to run IV fluids on him continuously for 5+ days? So now, instead of just slight bibasilar crackles like the first night I had him, he now has crackles all the way to under his shoulder blades. That he’s puffy like the Michelin man and we have to prop his scrotum up with towels because it is so edematous. Yes, as a matter of fact his saturations are within normal levels, but he doesn’t seem so peachy. He’s working a little harder to breathe and for the first time in 3 nights, when he got up to the bathroom to have a movement, he had an episode of chest pain, the first in his whole hospitalization. You say “call me if his respiratory status changes” but how about being pro-active and treating the issue before he decompensates and has to stay longer? Yes, I am a nurse, but you see your patients for 5 minutes a day, I’m with them 12 hours at a shot and get to know them, so when I ask if you’ve considered giving a little Lasix, I do have a clue and a reason for asking: I’m seeing a progression here that you and the Team are obviously missing. But I know, it’s nearly the end of June and you’re about to move up a year and have interns of your own, and not have to do the night shift as much anymore, but for now, can you just please treat my patient?

Oh, and while I’m at it, I know you guys have a quota for testing for C.Diff, but think about it before you do. When the you ask about the patients bowel habits and the nurse tells you that, “Well she had a couple loose stools, but days had given her Miralax, colace, senna and milk of mag,” the resulting loose stools is probably not C.Diff, just a side effect of over-medicating with stool softeners. If it was C.Diff, we’d tell you: if it looks like CDiff, acts like C.Diff (24 trips to the toilet in a shift) and mostly, smells like C.Diff, it probably is. If it doesn’t fit, why would you order the tests and the isolation it requires? And to add to that, when you’re sending a patient to my floor, you better tell us in advance that they are being ruled out for C.Diff because we have to give them a private room due to the contact isolation they must be in until they rule out for C.Diff.

Thanks and Best Regards,

The nurses who are trying to heal your patients.

Me. And my big mouth.

I did something stupid the other week. Something I regretted doing. It wasn’t dangerous, didn’t put any patients in peril, cause mass calamity on a national scale, nor promise unlimited health-care for all, nor deny inappropriate relations with a well-connected lobbyist, or drive my car into a train tunnel, but it was just stupid, and I paid for it.

About a week ago a resource nurse who comes to our floor a lot and I were talking and commiserating on the fact she had a trio of poopers. “All I’m doing tonight is cleaning up poop. Even though one has a flexi-seal, it’s still leaking out.” she said.

“Well at least you were prepared for it…your undershirt is kind of c-diffy colored…” I came back with.

“Yeah thanks, I know Captain Obvious.” she said, “It wasn’t the best choice. I should’ve known with this floor!”

And then I said it. The phrase that would doom me into poop-servitude: “Y’know, I haven’t had a night like that in a long time.” Stupid. Stupid. Stupid. It’s like saying “q—–” on a full-moon night, or “she’s finally asleep” about the demented old lady who had been trying to climb out of bed all night. In the grand karmic wheel of nursing, I just steeped in it.

So I show up Tuesday night, flushed with excitement from a nice ride into work, changed and ready to rock. And I start looking at my assignment.

#1: “bradycardia, s/p CV“. OK, he’s a walkie-talkie, fine.

#2: “synope” Again, OK, she looks like a walkie-talkie.

#3: “s/p CABG with AVR, post-op delirium and colitis.” Uh-oh…look a little further down the sheet on him, “mulitple loose stools, (c-diff – !)”
“Yep, could be fun but at least he doesn’t have c-dif,” I thought. Then I read a bit further, “Neuro: A & O x1-2, weak, 2+ assist up, left-sided weakness (new?), strict bedrest.” Now things were getting interesting.

#4: “sepsis, due to C-DIFF.” Yes, here it was the karmic retribution for the words so casually spoken the week before. “Neuro: confused and forgetful, A & O x1-2; Activity: up with 2+ max assist. GI/GU: foley, incont. of stool, 1 loose/mucoid stool.” That’s all of the report I needed. It was going to be one of those nights. Karmic payback.

The day nurse then told me, “Yeah, I d/c’d the flexi-seal yesterday.” I nod glumly, knowing that I would be spending quite a bit of time in the room that night.

So as the night evolved, I did the nursing thing. Checking briefs everytime I head into the room. 2100: still ok. 23:00: so far so good. 24:00, “awwww, hell naw”. Blow-out in #4….I felt like paging overhead, “clean-up on aisle three, clean-up on aisle three.” and clean-up we did. Nothing like a full-bed change blow-out session.

Then #3 rings, “yeah, I ate an apple, then I shit,” he says. That’s one of the things I love about old men, they’re so…well…honest. Clean him up. I’m out of the room less than 10 minutes, “Yeah,” as I answered the call-light,”I shit again.” And on, and on, and on. Cleaned him up 5 more times that night. The C-Diff lady? Nary a time after the blowout.

Fast forward to night #2. I still think I have poop on me somewhere. Even though I have new scrubs on and showered twice since being here. I can still sense it. Not really smell it, bu it more like sensing it, just out of conscious smell range, but there, like the lingering after scent of a bad bar night.

Same peeps. New issue though. Find out #3 has VRE. In his stool. That we had been cleaning for days on end. Without gowns. OK, so make that 2 peeps on contact precautions. And still pooping. Lots.

About midnight I call up Materials, “Hey, this is Wanderer up on 4. Can you send up some more of the big blue chux and another 4 or so packs of isolation gowns and a box of the peri-wipes? We’re going through them like they’re going out of style.”

And the battle continued. I think I singed off all of my olfactory nerve endings those 2 nights because I couldn’t smell anything when I go home in the morning. After I left each room, the smell no longer lingered, it’s like there was nothing for it to linger on. They were gone. Which I guess could be a good thing.

Onto Night 3.

Charge nurse (different on from the past 2 nights) hands me my assignment and says, “I took away #3 from you, it’s just not fair to have 2 isolation patients.”

“Uh. OK, I had them both last night…but I’m not going to complain.” I said. But in fact, it was worse. Instead of having 2 poopers, that I know well, and have kind of gotten used to their unique idiosyncrasies (i.e. smell), I get one and a new cast of characters.

In retrospect, it was OK. She was just spreading the love. Out of the 6 nurses on my particular side of the floor, everyone had at least 1 isolation patient, most were contact, for c-diff. So we all had the love that night.

But what did I learn?

Yes, never, ever, open your big mouth. Karma’s a bitch. Even though you know you’re due, just don’t say it. Let it go. Maybe you’ll stay free a little while longer.

That shoe covers are this year’s must have accessory!

And that I look good in yellow…