Clostridium difficile (C-difficile) is a common bacterium that is a frequent cause of infection in the colon and effects numerous patients. Clostridium difficile increases the hospital costs associated with inpatient care, including identification of the organism as well as treatment. The most common cause of C-difficile infection is the elimination of normal intestinal flora caused by antibiotic use. Standard treatment of C-difficile infection includes the use of oral (Flagyl) and intravenous (Vancomycin) antibiotic therapy. The use of fecal transplantation to treat C-difficile infection is increasing in popularity.
Research regarding fecal transplantation dates back to 1958; however, the efficacy of fecal transplant for the treatment of C-difficile are rapidly emerging with noted benefits for patients. The mere thought of presenting fecal transplantation for the treatment of a C-difficile infection is often dismissed because of limited available evidence and the concerns about using someone else’s stool to treat the infection. The necessity to educate patients with C-difficile is an additional challenge. Potential donors and recipients need to be assured of minimal risks associated with the screening and transplantation process.
The ability to educate society on the results of evidence-based practice regarding the treatment of C-difficile with fecal transplantation should minimize concerns and enhance patient outcomes. The creation of a patient education programs is increasingly beneficial when multiple health care professionals and interdisciplinary teams are involved. Thus, a project objective in implementing an educational patient program for fecal transplantation is the creation of an informative brochure for potential use in the Endoscopy Department at Sharp Memorial Hospital by December 2014.
The treatment regimen for initial and chronic C-difficile with fecal transplantation is inexpensive and noted as extremely effective. The articles reviewed consistently reveal efficacy rates greater than 85%. Fecal transplantation for the treatment of C-difficile continues to illicit multiple verbal and non-verbal responses and is not considered a standard of care for patients, families, communities, and hospital staff. The implementation of an informative educational brochure will minimize fears, hesitations, and reluctance for the treatment of C-difficile with fecal transplantation.
The central theme of transplanting feces from a selected healthy donor to the recipient with C-difficile is often met with resistance. The fecal transplantation brochure will encompass aspects of fecal transplantation with the expectation of educating patients, families, and communities. Additionally, the brochure would enhance awareness of hospital staff providing an opportunity to educate units or departments. The application of Kurt Lewin’s change model for the implementation of an educational brochure for fecal transplantation will be employed.
The current treatment modalities for C-difficile and the methods of transmission are increasingly becoming expensive for health care organizations. The financial goals of the organization are to decrease the rates of C-difficile and possibly entertain the concept of fecal transplantation. A dichotomous survey will be used to measure awareness and use of fecal transplantation for the treatment of C-difficile. The interdisciplinary team employed to create the brochure would prove beneficial in developing standardized procedures in performing fecal transplantations.
The Southern California Society of Gastroenterology Nurses and Associates is an excellent venue for potentially validating and communicating the results. The two possible grant funding sources for the fecal transplantation brochure is the American Gastroenterological Association (AGA) and the American Society of Gastroenterology Nurses and Associates (SGNA). The creation and implementation of an educational brochure for patients considered for fecal transplantation would enhance community education and minimize fears in treating C-difficile with fecal transplantation.
Keywords: fecal transplantation, clostridium difficile, fecal micobiota transplantation Problem Identification The traditional treatments for patients diagnosed with infections of the colon are antibiotics. However, many antibiotics kill the normal healthy bacteria of the colon. This results in an overwhelming increase in the risk for developing a C-difficile infection. Medicine. Net (2012) stated, “Patients taking antibiotics are at risk of becoming infected with C. difficile as antibiotics can disrupt the normal bacteria of the bowel, allowing C. ifficile to become established in the colon” (para. 1). The potential for implementing the use of fecal transplantations for the treatment of C-difficile among the general population is questionable. The mere thought of presenting fecal transplantation for the treatment of a C-difficile infection is often dismissed because of limited available evidence and the concerns about using someone else’s stool to treat the infection. Rohlke and Stollman (2012) stated, “Cure rates of > 90% are being consistently reported from multiple enters.
Transplantation [fecal] can be provided through a variety of methodologies, either to the lower proximal, lower distal, or upper gastrointestinal tract” (p. 403). An additional consideration is the perception of fecal transplantation within the community. The necessity to educate patients with C-difficile is an additional challenge. Potential donors and recipients need to be assured of minimal risks associated with the screening and transplantation process. Current research supports and discusses a comprehensive approach to identification and screening for potential fecal donors, donor preparation, and transplantation procedures.
The procedure for donor selection and screening is comprehensive to prevent the transmission of infection. According to Hamilton, Weingarden, Sadowsky, and Khoruts (2012), “The [donor] history includes assessment of infectious risk, including identification of known risk factors for HIV and Hepatitis, current communicable diseases, and recent travel to areas of the world with a higher prevalence of diarrheal illnesses” (p. 3). In educating patients, families, and the community at large, the rigor associated with the screening process must be emphasized to reduce fear.
The project objective in implementing an educational patient program for fecal transplantation is the creation of an informative brochure for potential use in the Endoscopy Department at Sharp Memorial Hospital by December 2014. The brochure will be created using a collaborative approach by employing endoscopic nursing champions. The goal is for the brochure to be patient specific and encompass appropriate information to decrease fears and answer questions associated with fecal transplantation.
Additionally, the development of a patient posttest associated with the brochure will be created to evaluate the effectiveness of content delivery and adjusted accordingly to meet patient needs and desired outcomes. The proposed solution will minimize the ambiguity and fears associated with fecal transplantation for the treatment of C-difficile. Solution Description The proposed solution for teaching potential recipients and donors about fecal transplantation for the treatment of C-difficile is to diminish infection rates.
By creating and implementing a comprehensive nursing educational approach patients and donors can be well informed on this innovative treatment modality. “In many areas of clinical decision making, research has demonstrated that “tried and true” practices taught in basic nursing education are not always best” (Polit & Beck, 2012, p. 25). The ability to educate society on the results of evidence-based practice regarding the treatment of C-difficile with fecal transplantation should minimize concerns and enhance patient outcomes.
The creation of a patient education program is increasingly beneficial when multiple health care professionals and interdisciplinary teams are involved. The importance of evidence-based practice is to ensure the evidence about fecal transplants has been collected, evaluated, and implemented to establish the best practice and approach. The main premise for patient safety is to ensure donors have been thoroughly screened to minimize the potential for the transmission of other diseases with feces.
According to Rohlke and Stollman (2012) on donor selection, “There have not yet been any adverse events reported that can be conclusively or directly attributed to [fecal microbiota transplantation] FMT, and proper donor screening is essential to avoid transmitting communicable diseases from donor to recipient” (p. 406). Individuals with recurrent C-difficile infections are moderately self-educated regarding treatment modalities and are receptive to the idea of fecal transplantation.
The emphasis on educating patients, families, and communities regarding fecal transplantation as the initial treatment regimen is the focus. Hospital and individual associated costs in administering antibiotic therapy for the treatment of C-difficile could be drastically reduced by using fecal transplantation as the initial therapy. Brandt (2012) stated in reply, “Do patients typically accept fecal transplantation as a treatment option? Yes …patients typically respond with interest, and they are generally positive about trying it and they do not typically react with disgust” (para. ). The current research base associated with fecal transplantation demonstrates high cure rates while minimizing the reoccurrence of C-difficile. Rohlke and Stollman (2012) stated, “Cure rates of > 90% are being consistently reported from multiple centers” (p. 403). The review of current literature demonstrates that patient education for fecal transplantation is performed by a gastroenterologist and not the gastrointestinal (GI) nurse. Patient education provided to patients from physicians typically entails a one-way communication style.
In this scenario, the gastroenterologist sends the information to the patient, and there is little discussion with the receiver. Thus, patients commonly seek out more information from the registered nurse. The ability to educate patients regarding fecal transplantation using the proposed brochure would facilitate a commonality and minimize fears. The feasibility of implementing the brochure into endoscopic departments would be perplexing and centered on nursing knowledge of fecal transplantation. Brodine and Kellogg (2013) stated, “All patients infected or colonized with C. ifficile must be educated about this bacterium, proper disease management, and transmission prevention. The nurse should use patient-centered communication—free of jargon and appropriate to the patient’s health-literacy level” (para. 13).
The health care organization must employ educational programs specific to the needs of the patients and desired outcomes. “The Joint Commission recommends using the “teach-back” and “show-back” methods to educate patients; that is, ask the patient to “teach back” the information provided or demonstrate understanding by “showing” a skill…” (Brodline & Kellogg, 2013, para. 3). The organizational culture at Sharp Memorial Hospital for nursing is centered on the American Nurses Credentialing Center (ANCC) Magnet Recognition Program®. The nursing strategic plan is developed by nursing leaders with input from nursing staff based on the hospital strategic plan. Additionally, nurse leaders emphasize that innovation is a core value and part of the nursing process.
Nurse leaders encourage innovation through training, resources, and role modeling (Beyond Excellence, 2013). The roposed solution of implementing patient education for fecal transplantation is supported by Sharp Memorial Hospital because it involves introducing new knowledge regarding innovative, evidence-based treatment modalities. Research Report Clostridium difficile infection remains a constant struggle for hospitals. The standard treatment regimen of antibiotics commonly results in relapses. Research on fecal transplantation is continuing to emerge as a promising alternative approach in treating chronic C-difficile infections.
Numerous studies demonstrate positive outcomes with the administration of fecal transplant in the treatment of C-difficile (Rohlke & Stollman, 2012). Fecal transplantation has shown through research studies to be a useful treatment for C-difficile infection via the restoration of intestinal normal flora (Brandt, 2012).
The most common sign reported by patients diagnosed with C-difficile is chronic diarrhea. Johnson (2012) stated, “The administration of antibiotics can alter the balance of normal colonic flora to permit the overgrowth of pathogenic C. ifficile strains that produce toxins which cause diarrhea and associated symptoms” (para. 5). In an article published in the Alimentary Pharmacology and Therapeutics, the authors reported 17 of 22 fecal transplantations for the treatment of C-difficile were effective (Landy, Al-Hassi, MLaughlin, Walker, Nicholls, Clark, & Hart, 2011). The substantiated results of the review article highlighted major differences in patients, donors, screening, methods of administration, and the definition of treatment responses (Landy et al. , 2011).
The multiple factors highlighted in this review of treating C-difficile with fecal transplantation review across the spectrum using a standard approach is essential to supporting increased use of this treatment modality. Landy et al. (2011) stated, “Standardized controlled studies are necessary to ascertain the most effective treatment regimen as well as the most acceptable method of treatment” (p. 414). Grehen, Borody, Leis, Campbell, Mitchell, and Wettstein (2010) published a study, “to demonstrate the benefits of fecal biotherapy and the role of new therapeutic strategies for the treatment of gastrointestinal conditions” (p. 51). The study included 10 patients treated with fecal transplantation and monitored the progress of bacterial population of the colon pre and post transplantation for a 24 week period.
Grehen et al. (2010) found the following: At intervals of 4, 8, and 24 weeks after the procedure, the bacterial populations in the patients’ fecal samples consisted predominantly of bacteria derived from the health donor samples. Comparisons of similarity at 4, 8, and 24 week samples to the donor-infused sample were made and each recipient’s baseline sample was statistically significant with Friedmen test. p. 551) Rohlke and Stollman (2012) noted that C-difficile rates continue to rise with greater intensity and severity. The treatment of C-difficile with fecal transplantation is an emerging and accepted intervention in patients with recurrent C-difficile. Rohlke and Stollman (2012) stated, “Cure rates of >90% are being consistently reported from multiple centers. Transplantation can be provided through a variety of methodologies, either to the lower proximal, lower distal, or upper gastrointestinal tract” (p. 403).
The review by Rohlke and Stollman (2012) analyzed reports validating the factors of “donor selection, appropriate patient criteria, and the preparations and mechanisms of fecal microbiota transplant delivery available to clinicians and patients” (p. 403). The internal validity of the research articles reviewed demonstrates moderate samples were randomly selected. The current literature validated the need for more randomized controlled studies to determine established guidelines for the implementation of fecal transplantation.
Additionally, the treatment regimen for initial and chronic C-difficile with fecal transplantation is inexpensive and noted as extremely effective. The independent variable of the effectiveness of fecal transplantation for the treatment of C-difficile remained a consistent theme. The articles reviewed consistently reveal efficacy rates greater than 85%. The external validity of the study articles revealed fecal transplantation processes are varied in the process of which patients are treated, the donor selection criteria, donor screening protocols, and the methods of delivery.
The outcomes of the results reported are moderately consistent; however, the ability to generalize a standardized treatment pathway is ambiguous and larger multi-organizational and multi-disciplinary studies are essential. Rex (2012) found the following: Several studies of fecal transplantation have demonstrated high cure rates. The latest and largest to date is a retrospective case series involving 70 patients in Finland (mean age, 73; 86% outpatients). Overall, 94% of these patients had symptom resolution during the first 12 weeks after transplantation, including 32 of the 36 infected with the O27 strain of C. ifficile and all 34 of those infected with other strains. No immediate complications occurred. (para. 1)
Fecal transplantation in the treatment for C-difficile has proven to be highly successful in a limited number of studies. In determining if fecal transplantation should be the standard of treatment for C-difficile infection, larger controlled studies are required. Additionally, a standard process related to donor screening, implantation techniques, transplant follow-up, and regularly documenting patient outcomes are essential in establishing standardized fecal transplantation protocols.
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