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Preventing Health Care-Associated Infection: Development of a Clinical Prediction Rule for Clostridium Difficile Infection. By

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Preventing Health Care-Associated Infection: Development of a Clinical Prediction Rule for Clostridium Difficile Infection. By Preventing Health Care-Associated Infection: Development of a Clinical Prediction Rule for Clostridium difficile Infection. by Greta L. Krapohl A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Nursing) in the University of Michigan 2011 Doctoral Committee: Professor Richard W. Redman, Co-Chair Emeritus Professor Bonnie L. Metzger, Co-Chair Professor Marita G. Titler Associate Professor Allison E. Aiello Assistant Professor Akke Neeltje Talsma © Greta L. Krapohl 2011 Dedication To the patients that have suffered from Clostridium difficile infection. ii Acknowledgements "Man's mind, once stretched by a new idea, never regains its original dimensions." -Oliver Wendell Holmes, US author & physician (1809 - 1894). The University of Michigan has given me the most well-rounded, challenging and thorough education I could have ever imagined. Not only did it give me the opportunity to ―stretch my mind beyond its original dimensions,‖ but I have had the great pleasure to meet some of the smartest, talented, and interesting faculty and staff from across the entire campus. I would like to start out by acknowledging my Co-Chairs, Dr. Bonnie Metzger and Dr. Richard Redman, both of whom have been there for me through every phase of my doctoral education and who are deserving of my deepest, heartfelt gratitude. Dr. Metzger has given me unfailing support, generous amounts of her time and has both challenged and inspired me when I needed it the most. It is fitting that the quote above was a part of her official electronic signature block as Dr. Metzger has changed the way I will think about nursing-- forever. As for Dr. Redman, he is an exemplar of an extraordinary nursing leader. Under his tutelage, I have had the opportunity to learn and grow both personally and professionally. I credit both of them as key forces in helping me to achieve success. I would like to extend my sincere gratitude to three additional faculty members from outside of the School of Nursing who have given me tremendous guidance and iii support throughout my research. The first is Allison Aiello at the School of Public Health, my cognate committee member, whose expertise in epidemiology was invaluable as I progressed through the research process. The other is Christine Feak, from the English Language Institute, who gave me the skills, knowledge, support, and finally, the confidence, to develop my writing ability. It was in her class, one of the best that I took here at Michigan, where I discovered how to ―unlearn‖ in order to improve and refine my scientific writing ability. And finally, a special debt of gratitude is extended to Dr. Darrell Campbell, an extraordinary physician and leader, who was willing to take a chance on me and include me with the ―varsity team‖ at the Michigan Quality Surgical Collaborative (MSQC). The data from this collaborative program made this research possible. I would like to thank the following faculty for ‗stretching‘ my mind in such a way that I have acquired a new appreciation for the dedication, responsibility and commitment required to achieve excellence as a nursing scientist: Akkneel Talsma and Marita G. Titler (committee members), Milisa Manojlovich, David Ronis, Laurel Northouse, Christine Anderson, Antonia Villarruel, Reg Williams, Carolyn Sampselle, Carol J. Loveland-Cherry, Barbara Therrien, Arden Morris MD, Samantha Hendren MD. Their input has contributed immensely to advancing my thinking and forging my new ‗dimensions.‘ If I had to name the most important resources for success of my doctoral education, it would come down to these three: The Center for Statistical Consultation and Research (CSCAR), the Taubman Health Sciences Library, and the National Institute of Nursing Research. Special thanks to Dr. Ed Rothman, the director of CSCAR, who iv provides the leadership and positive climate for a first-class consulting team. I would especially like to recognize one member of the CSCAR faculty, Joe Kazemi, whose assistance was invaluable in helping to make sure my analysis and interpretation was on target. I also want to convey sincere appreciation to the librarians at the Taubman Health Sciences Library who were a constant source of support and assistance during all the phases of my education at Michigan. Deborah Lauseng, the School of Nursing consultant, was especially helpful in making sure my work reflected the most current state-of-the-science and Carol Shannon for helping me to wrestle (and win!) with Endnote. I am deeply grateful for the financial support I received from the National Institute of Nursing Research (Award Number F31NR011548) to complete my research. This financial support not only gave me the opportunity to focus on my research full- time, but has given me a new found appreciation for the importance of nursing research as a national priority. I was warned that pursuing a PhD is a lonely pursuit, but I have found just the opposite. I have thoroughly enjoyed the fellowship and camaraderie of my fellow classmates. In particular, I would like thank my ―dissertation support group,‖ Crystal, Gay and Deleise as well as those I have had the privilege to work with closely— Elisa, Amby, Yung-ping, Moira, Missy, Jesse, Penny and Ann. I would also like to extend a special thank you to my inner group of friends that have helped me in very special ways and when it was most critical: Gretchen, Cathy, Yeong, Karen, Fei-Fei, Lewis, Kara, Susan, Kitsy and Dan. Finally, I would like to thank my family for giving me the support, love and continuous encouragement I needed to complete this journey. A sincere thank you to my v mother and father for always believing in me and most importantly, teaching me what matters and what does not. Likewise, I would like to thank my in-laws, Patricia and Jack Krapohl, for their unfailing support each and every step along the way. There is no denying that this academic accomplishment could not have been possible without their help. And with the deepest love and gratitude, for which words fall short to convey, thank you to my husband Graydon and my daughter Grace ……..for making it all worthwhile. vi Table of Contents Dedication ...................................................................................................................... ii Acknowledgements ....................................................................................................... iii List of Figures .................................................................................................................x List of Tables................................................................................................................. xi List of Appendices ........................................................................................................ xii Abstract ....................................................................................................................... xiii Chapter I. Introduction ....................................................................................................1 Health Care-Associated Infections: Defined ...............................................................4 Key factors in the cause of HAI. .............................................................................4 Hospital practices to prevent HAI. ..........................................................................6 Clinical Prediction Rules ......................................................................................... 10 Types of clinical prediction rules .......................................................................... 11 Methodology of development. .............................................................................. 12 Clinical application for HAI. ................................................................................ 14 Pitfalls. ................................................................................................................. 17 Nursing implications. ........................................................................................... 18 Conceptual Framework ............................................................................................ 18 Chapter II. Background and Significance ...................................................................... 23 The Health care- Associated Infection of Clostridium difficile ................................. 23 Clinical Presentation and Treatment. .................................................................... 23 Pathogen and Pathogenesis. .................................................................................. 25 Detection & Surveillance. ..................................................................................... 27 Community-Acquired vs. Hospital-Acquired CDI. ............................................... 28 Exposure: The Transmission of CDI in Hospitals. ............................................... 29 vii Host Defense in CDI: Patient Characteristics and Treatment-Related Variables. .. 32 Summary ................................................................................................................. 39 Chapter III. Methodology ............................................................................................. 41 Aims ........................................................................................................................ 41 Research Design and Methods ................................................................................. 42
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