IHI Expedition Reducing Clostridium difficile Infections Session 3: - - PDF document

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IHI Expedition

Reducing Clostridium difficile Infections Session 3: Symptom Recognition, Precautions, and the Role of the Environment

July 23, 2014

These presenters have nothing to disclose

Brian Koll, MD Carolyn Gould, MD Diane Jacobsen MPH, CPHQ

Expedition Coordinator

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Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action

• n Avoidable Rehospitalizations (STAAR) Initiative, the

Summer Immersion Program, and IHI’s efforts for Medicare-Medicaid enrollees. Kayla leads IHI’s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the

• rganization’s first employee health risk assessment, Kayla

is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration.

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Expedition Director

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Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI) is currently directing the CDC/IHI Antibiotic Stewardship Initiative, NSLIJ/IHI Reducing Sepsis Mortality Collaborative. Ms. Jacobsen served as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) and directed Expeditions

• n Antibiotic Stewardship, Preventing CA-UTIs,

Reducing C.difficle Infections, Sepsis, Stroke Care and Patient Flow. She served as faculty for IHI’s 100,000 Lives and 5 Million Lives Campaign and directed improvement collaboratives on Sepsis Mortality, Patient Flow, Surgical Complications, Reducing Hospital Mortality Rates (HSMR) and co-directed IHI’s Spread

• Initiative. She is an epidemiologist with experience in

quality improvement, risk management, and infection control in specialty, academic, and community hospitals. A graduate of the University of Wisconsin, she earned her master’s degree in Public Health- Epidemiology.

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Today’s Agenda

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Introductions Action Period Assignment Debrief Symptom Recognition, Precautions, and the Role of the Environment Action Period Assignment

Expedition Objectives

At the end of this Expedition, participants will be able to: Explain the impact of the increasing incidence and severity of C. difficile on hospitals Discuss key approaches to preventing the spread of C. difficile in the hospital setting Identify and begin improving at least one key process for impacting C. difficile in their hospital

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Schedule of Calls

Session 1 – Making the Case for Reducing Clostridium difficile Infections (CDI) Date: Wednesday, June 25, 2:00 – 3:30 PM ET Session 2 – Rapid Detection and Isolation Date: Wednesday, July 9, 2:00 – 3:00 PM ET Session 3 – Symptom Recognition, Precautions, and the Role of the Environment Date: Wednesday, July 23, 2:00 – 3:00 PM ET Session 4 – Antibiotic Stewardship Date: Wednesday, August 6, 2:00 – 3:00 PM ET Session 5 – The Role of Leadership Date: Wednesday, August 20, 2:00 – 3:00 PM ET Session 6 – Transitions and Long- term Care Date: Wednesday, September 3, 2:00 – 3:00 PM ET

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Action Period Assignment

Rapid detection and precautions for C diff – test a process:

To expedite patients being placed on contact precautions when C diff is suspected or confirmed

• Test a flag, prompt, etc. to automatically initiate contact precaution when

CDI test is ordered. (one unit, one nurse/unit clerk, refine based on initial test)

• Test a process to review patient placed on oral metronidazole or oral

vancomycin, for need for contact precautions (one unit, one pharmacist/nurse, one day on MDR’s – refine based on initial test)

• Test a process to enhance STAT reporting of CDI, ie: critical value

(one unit, one week, partner with laboratory – refine based on initial test) What did you test/learn? Insights? Surprises?

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Faculty

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Brian Koll, MD, FACP, FIDSA, Executive Director for Infection Prevention, the Mount Sinai Health System, New York, NY, is a nationally-renowned and award-winning infection prevention expert. He has been featured on CBC Evening News for successful efforts to reduce central line associated bloodstream infections, on World News Tonight for successful efforts to control

• C. difficile, and in a national public service

announcement regarding this disease by the Peggy Lillis Memorial Foundation.

Faculty

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Carolyn Gould, MD, MSCR, is a board-certified Infectious Diseases physician and Medical Epidemiologist in the Division of Healthcare Quality Promotion at CDC. Dr. Gould joined the CDC and the Commissioned Corps of the US Public Health Service in December 2006. Her primary roles involve responding to and preventing healthcare-associated infections in acute care settings, with a special expertise in C. difficile infections, catheter-associated urinary tract infections (CAUTI), and antimicrobial stewardship.

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A Tiered Approach to Reduce Hospital Onset C. difficile

Brian Koll, MD, FACP, FIDSA Executive Director, Infection Prevention and Control, Mount Sinai Health System Professor of Medicine, Icahn School

• f Medicine

Tiered Approach

1.

Hand hygiene

2.

Contact precautions

3.

Sign placement

4.

PPE readily available and used

5.

Dedicated rectal thermometers

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Tiered Approach

6.

Patient placement

7.

Commodes

8.

Environmental cleaning protocols

9.

Chlorhexidine bathing

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Tiered Approach

• 10. Antibiotic stewardship
• 11. Pharmaceutical

stewardship

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Begins with Leadership

• Accountability
• Link infection prevention

with organizational strategy and resources

• Link a culture of safety to
• utcomes
• Engage and facilitate

teamwork

• Goal setting and

measuring and assessing effectiveness

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Begins with Leadership

▶ All Formal Authority Positions

– Chairs, Chiefs, Managers, Directors, Supervisors

▶ All Physicians ▶ Informal Leaders

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Begins with Those on the Front Line

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Begins with Diarrhea

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Isolation and Precautions

• Signage
• Availability of gowns, gloves, masks and N95

respirators

• Dedicated storage
• Monitoring of isolation rooms
• Cleaning of equipment between patients
• Hand hygiene
• Patient placement
• Private Room
• Cohorting

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Begins with Those on the Front Line Ownership

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MDRO Infection Prevention Bundles 2011 – 2013

20 30 40 50 60 70 80 90 100 J2011 M M J S N J2012 M M J S N J2013 M M A O D Compliance Rate % Time MSBI MSBIB

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Environmental Contamination

• Environmental cultures:
• 100% of CDAD rooms with >1 positive culture.
• 33% of non-CDAD rooms with >1 positive culture.
• C. difficile has been recovered from up to 58% of

individual samples from patient rooms.

• Beds, stretchers, wheelchairs, sinks, toilets, walls, iv poles,

blood pressure cuffs.

• Outbreaks have been associated with reusable

rectal thermometers.

• Dubberke. Am J Infect Control 2007;35:315-8
• Martirosian. J Clin Microbiol 2006;44:1202
• Walker. J Hosp Infect 2006;epub April 6

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Environmental Contamination

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Environmental Contamination

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Environmental Disinfection

Eckstein et al. BMC Infectious Diseases 2007 7:61 Percentage of positive environmental cultures before and after housekeeping cleaning and after research team disinfection with 10% bleach. (9 rooms)

Impact of Environmental Disinfection

Mayfield JL. Clin Infect Dis 2000;31:995-1000

Quaternary ammonium 10% bleach Quaternary ammonium 8.6* 8.1* 3.3*

*cases per 1000 pt-days

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Monitoring of Environmental Cleaning

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Begins with Those on the Front Line Ownership

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Environmental Cleaning Ownership by the Department

10 20 30 40 50 60 70 80 90 2011 2012H1 2012H2 2013Q1

Cleaning Compliance Rate

EVS IC

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A Picture Says One Thousand Words

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Handling of Linen

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Must be covered No overflowing linen bins Linen bins should be separated from clean equipment

Sani Cloths and Dispatch

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• Two minute kill time – CDI kill time is five minutes
• Tops must be covered
• Check expiration dates

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Begins with Those on the Front Line Ownership - Nursing

University of Nebraska

1.

bathing three days per week followed by

2.

daily bathing followed by

3.

four-month washout period returning to standard soap-and-water bathing

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Infect Control Hosp Epidemiol 2012;33:1094 - 1100

Begins with Those on the Front Line Ownership - Nursing

30% reduction in HO CDI with three days per week protocol 59% reduction with daily bathing

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Infect Control Hosp Epidemiol 2012;33:1094 - 1100

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HO CDI

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Tiered Approach

1.

Successful

2.

Involvement at all levels of the

• rganization

3.

Sustainable results

4.

Assure continued improvement

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Questions?

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Raise your hand Use the Chat

Carolyn Gould, MD, MSCR

Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

IHI CDI Expedition Session 3: Symptom Recognition, Precautions, Role of the Environment

Prevention of Clostridium difficile Infections

National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

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CDC highlights preventing CDI

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm

Vital Signs: 6 Key Components

• f Prevention

 Prescribe and use antibiotics carefully  Focus on an early and reliable diagnosis  Isolate patients immediately  Wear gloves and gowns for all contact with patient

and patient care environment

 Assure adequate cleaning of the patient care

environment, augment with EPA-registered C. difficile sporicidal disinfectant

 Notify facilities upon patient transfer

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm

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Vital Signs: 6 Key Components

• f Prevention

 Prescribe and use antibiotics carefully  Focus on an early and reliable diagnosis  Isolate patients immediately  Wear gloves and gowns for all contact with patient

and patient care environment

 Assure adequate cleaning of the patient care

environment, augment with EPA-registered C. difficile sporicidal disinfectant

 Notify facilities upon patient transfer

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm

Early Detection and Isolation

Screen patients for new-onset diarrhea on admission and

• n a regular

basis Facilitate early testing Consider nurse-driven protocols Pair testing with

• rder for Contact

Precautions Use more sensitive testing methods

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Optimizing Testing

 Enzyme immunoassay (EIA) for toxin sensitivity 48%-

67%

 More sensitive tests:

• Nucleic-acid amplification tests (NAAT)
• Polymerase chain reaction (PCR)
• Loop-mediated amplification (LAMP)
• 2- or 3- step testing algorithms using GDH + toxin testing of

positive specimens

• GDH less sensitive (79%-98%) compared to NAAT or toxigenic

culture in a recent meta-analysis

Tenover FC, Novak-Weekley S, Woods CW, et al. J Clin Microbiol 2010; 48:3719–24 Tenover et al. J Mol Diagn 2011;13:573-82 Peterson et al. Clin Infect Dis 2007;45:1152-60 Shetty et al. J Hosp Infect 2011;77:1-6

First and Foremost…

• For any testing method, you need a favorable pre-

test probability of disease for optimal performance

– Diagnostic accuracy improves with increasing prevalence of disease in the population tested

• That means testing appropriately:

– Watery/unformed stool (conforms to shape of container) – At least 3 unformed stools in 24 hours – Avoidance of repeat testing, tests of cure

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Potential Benefits of More Sensitive Testing

 Fewer isolation days for negative patients  Fewer repetitive tests performed (46% at one institution

with restriction rules in place)

 In theory, earlier treatment initiation, reduced

complications, and improved infection control

Gould et al. CID 2013;57:1304 Moehring et al. ICHE 2013;34:1055-61 Loo VG, Frenette C. Presented at ICAAC 2011. Abstract D-1273 Morgan M, Grein J, Ochner M, Hoang H, Jin A, Murthy R. Presented at ICAAC 2011 Belmares J, Pua H, Schreckenberger P, Parada J. [abstract 150]. Presented at SHEA 2011 Annual Scientific Meeting, 1–4 April, 2011; Dallas, TX Goldenber g SA et al. ICHE 2011

Environmental Cleaning: use of Sporicidal Agents

• EPA registered disinfectants with sporicidal claim:

http://www.epa.gov/oppad001/chemregindex.htm

• Limited data suggest disinfecting with bleach (1:10

dilution prepared fresh daily) reduces C. difficile transmission in units with high endemic rates

• Therefore, sporicidal agents may be most effective

in reducing burden where CDI is highly endemic

Mayfield et al. Clin Infect Dis 2000;31:995-1000 Wilcox et al. J Hosp Infect 2003;54:109-14

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Current list of Agents with C. difficile EPA Sporicidal Claim (list K) (N=25)

Product: ACTIVATE 5.25% INSTITUTIONAL BLEACH Registrant: DEARDORFF FITZSIMMONS CORPORATION Active Ingredient: Sodium hypochlorite 5.25% Product: AUSTIN A-1 ULTRA DISINFECTING BLEACH Registrant: JAMES AUSTIN COMPANY Active Ingredient: Sodium hypochlorite 6% Product: BUSTER Registrant: CLOROX PROFESSIONAL PRODUCTS COMPANY Active Ingredient: Sodium hypochlorite 8.5% Product: CLOROX ULTRA BLEACH 2 Registrant: CLOROX PROFESSIONAL PRODUCTS COMPANY Active Ingredient: Sodium Hypochlorite 6.15% Product: CONCENTRATED CLOROX GERMICIDAL BLEACH1 Registrant: THE CLOROX COMPANY Active Ingredient: Sodium hypochlorite 8.25% Product: CPPC TSUNAMI Registrant: CLOROX PROFESSIONAL PRODUCTS COMPANY Active Ingredient: Sodium hypochlorite .55% Product: DISPATCH HOSPITAL CLEANER DISINFECTANT WITH BLEACH Registrant: CLOROX PROFESSIONAL PRODUCTS COMPANY Active Ingredient: Sodium hypochlorite .65% Product: DISPATCH HOSPITAL CLEANER DISNEFECTANT WITH TOWELS Registrant: CLOROX PROFESSIONAL PRODUCTS COMPANY Product: FF-ATH Registrant: ECOLAB INC. Active Ingredient: Ethaneperoxoic acid 5.8%, Hydrogen Peroxide 27.5% Product: GERONIMO 160A Registrant: KIK INTERNATION INC. Active Ingredient: Sodium hypochlorite 8% Product: HASTE-SSD-COMPONENT A Registrant: STERIS CORPORATION Active Ingredient: Tetraacetylethylenediamine 61.6% Product: HASTE-SSD-COMPONENT B Registrant: STERIS CORPORATION Active Ingredient: Hydrogen Peroxide 1% Product: KIMTECH GERMICIDAL WIPE Registrant: KIMBERLY-CLARK GLOBAL SALES, LLC Active Ingredient: Ethaneperoxoic acid .23%, Hydrogen Peroxide 4.4% Product: MASSASOIT A Registrant: KIK INTERNATIONAL INC. Active Ingredient: Sodium hypochlorite 8% Product: METACOMET 160B Registrant: KIK INTERNATIONAL INC. Active Ingredient: Sodium hypochlorite 8.25% Product: OSCEOLA 160C Registrant: KIK INTERNATIONAL INC. Active Ingredient: Sodium hypochlorite 8.5% Product: PERIDOX RTU ™ Registrant: BIOMED PROTECT, LLC Active Ingredient: Ethaneperoxoic acid .23%, Hydrogen Peroxide 4.4% Product: PURE BRIGHT GERMICIDAL 160 BLEACH Registrant: KIK INTERNATIONAL INC. Active Ingredient: Sodium hypochlorite 6% Product: PURE BRIGHT GERMICIDAL ULTRA BLEACH Registrant: KIK INTERNATIONAL INC. Active Ingredient: Sodium hypochlorite 6% Product: RESTROOM CLEANER & DISINFECTANT Registrant: ECOLAB INC. Active Ingredient: Sodium hypochlorite 2.15% Product: SANI PROFESSIONAL BRAND NOROCLOTH GERMICIDAL DISPOSA Registrant: PROFESSIONAL DISPOSABLES INTERNATIONAL, INC. Active Ingredient: Sodium hypochlorite .63% Product: STERIPLEX SD PART A Registrant: SBIOMED, LLC Active Ingredient: Silver .015% Product: TECUMSEH B Registrant: KIK INTERNATIONAL INC. Active Ingredient: Sodium hypochlorite 8.25% Product: VIRASEPT Registrant: ECOLAB INC. Active Ingredient: Ethaneperoxoic acid .05%, Caprylic acid .099%, Hydrogen Peroxide 3.13% Product: WAMPATUCK C Registrant: KIK INTERNATIONAL INC. Active Ingredient: Sodium hypochlorite 8.5%

http://www.epa.gov/oppad001/list_k_clostridium.pdf Updated August, 2012

Assess Adequacy of Cleaning Before Changing to New Cleaning Product

Carling et al. Clin Infect Dis 2006;42:385-8.

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http://www.cdc.gov/HAI/recoveryact/stateResources/stateResources.html

Environmental Cleaning Evaluation Toolkit

Assessing Environmental Cleaning: ATP Method Compared to Fluorescent Marker

 30 rooms of recently discharged patients, pre- vs. post

cleaning

 Larger relative light unit (RLU) and fluorescent marker (FM)

reductions seen on

• Bed control panel, phone, TV remote, bedside table

compared to:

• Bathroom flush handle/grab bar, IV pole, bedrail, door handle

 Greater RLU reductions associated with FM removal for the

first set of surfaces

 Discrepancies on other surfaces

• Differential adherence to cleaning vs. surface characteristics vs.

limitations of methods?

Murray et al. A comparison of ATP bioluminescence with surface fluorescent marker in assessing hospital room cleaning. Abstract: Am Society for Microbiology 114th General Meeting, May 14-17, 2014, Boston, MA.

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Mechanical Spore Removal: Though Much Can be Achieved, Still More to Be Done

• Wiping alone (25 sq.cm.)

– Nonsporicidal disinfectant: 2.90 log reduction – Sporicidal disinfectant: 3.70 log reduction

• Spraying alone

– Sporicidal disinfectant: 3.40 log reduction – Prolonged drying times and no removal of debris

“We believe the use of a wiping procedure with a sporicidal agent provides excellent removal and inactivation of spores and is an integral part of C. difficile control measures.”

Rutala et al. Infect Control Hosp Epidemiol 2012;33(12):1255-1258

How Could Non-sporicidal Disinfectants Fail in Practice?

• “Clean bench top surface” inoculated with 105 dried spores
• 10 second wipe with:

– Fresh hypochlorite wipe – Used hypochlorite wipe (expended on 25 sq.ft. surface) – Wipe saturated with quaternary ammonium agent

• Wipe (10 sec) of 4 successive “clean sites”
• 5 minute contact/drying
• Swab sampling of “sites”

– vortex in neutralizer, – plated on agar

Cadnum JL et al. Infect Control Hosp Epidemiol 2013;34(4):441-2

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Success in Reducing CDI Using a Sporicidal Wipe for Daily and Terminal Cleaning

• Before/after study in two high-risk medical wards
• Intervention:

– Daily and terminal cleaning of ALL rooms with ATP monitoring before/after (similar pass rate) – Quaternary ammonium compound before – Hypochlorite wipes with 10 minute contact time after

• Results: 24.2 to 3.6 cases per 10,000 patient-days (85% decline)

Orenstein et al. Infect Control Hosp Epidemiol 2011;32(11):1137-1139

Role of asymptomatic shedders in C. difficile transmission?

 To what degree do asymptomatic carriers spread spores

to the environment?

 How long do patients continue to shed after treatment?

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Asymptomatic carriers are a Potential Source for Transmission of C. difficile among LTCF Residents

Riggs et al. Clin Infect Dis 2007;45:992–8

Post Symptomatic CDI Carriage: Particularly Contagious Asymptomatic Carriers?

Sethi AK et al. Infect Control Hosp Epidemiol 2010; 31:21-27

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Only ~30% of Hospital-associated CDI Linked to Previous Symptomatic Cases

 Using advanced, highly discriminatory typing  At least 29% definitively linked to asymptomatic

carriers

 Transmission between wards common  Limitation: study did not use molecular diagnostics

• Expect a greater proportion linked to prior symptomatic patients

(CDI) with increased sensitivity

 Implications?

• Should we test for asymptomatic carriage?
• Special measures for asymptomatic carriers – e.g., gloves,

sporicidal disinfectants?

Curry et al. CID 2013, McDonald CID 2013

Contaminated Hands: Remember the Patients!

Donskey et al. Infect Control Hosp Epidemiol 2014;35:204

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Photo Title – Myriad Pro, Bold, Shadow, 20pt

Caption for photo, references, citations, or credits – Myriad Pro, 14pt For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank you! Questions?

National Center for Emerging and Zoonotic Infectious Diseases Place Descriptor Here

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Questions?

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Raise your hand Use the Chat

Action Period Assignment

Role of the environment:

Test a checklist to assess terminal Environmental cleaning: | * your current internal checklist and/or: “CDC Environmental Checklist for Monitoring Terminal Cleaning”

• Does your current process/procedure address all the components of the CDC checklist?

(ie: are there additional that your organization has identified as necessary/important? Are there components you can add to enhance your current process?)

• Request input/feedback on current process from:

1) Environmental Services: current barriers/constraints they encounter in completing terminal cleaning (ie: adequate time to turn around room? Reliable notification of patient w/C diff being moved/discharged? Other? ) 2) Nursing: are there current constraints (ie: ensuring Env Services are promptly & reliably notified if C diff? High census? Lack of private rooms? Other?)

Incorporate input from Nursing and/or Environmental Services to test a change to your current process

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– To add colleagues, email us at info@ihi.org – Pose questions, share resources, discuss barriers or successes

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Next Session

Session 4: Antibiotic Stewardship Wednesday, August 6, 2:00 PM – 3:00 PM ET Faculty: Belinda Ostrowsky MD & Phillip Chung PharmD

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