10/16/2014 July 9, 2014 These presenters have nothing to disclose IHI Expedition Reducing Clostridium difficile Infections Session 2: Rapid Detection and Isolation Brian Koll, MD Cliff McDonald, MD Diane Jacobsen MPH, CPHQ Today’s Host 2 Morgen Palfrey, Project Coordinator, Institute for Healthcare Improvement, is the current coordinator for web- based Expeditions. She also contributes to the IHI Leadership Alliance, the Always Project, and works with Strategic Partners in Singapore. Morgen is a member of Work- Life Wellness Team and Diversity and Inclusion Council at IHI, where she and fellow staff members develop strategies for improving the mind and body. Morgen graduated from the University of Florida in Gainesville, FL where she received her Bachelor of Arts degree in Political Science with a concentration in Public Administration. 1
10/16/2014 Audio Broadcast 3 You will see a box in the top left hand corner labeled “ Audio broadcast .” If you are able to listen to the program using the speakers on your computer , you have connected successfully. Phone Connection (Preferred) 4 To join by phone : 1) Click the button on the right hand side of the screen. 2) A pop-up box will appear with call in information. 3) Please dial the phone number , the event number and your attendee ID to connect correctly . 2
10/16/2014 5 Audio Broadcast vs. Phone Connection If you using the audio broadcast (through your computer) you will not be able to speak during the WebEx to ask question. All questions will need to come through the chat. If you are using the phone connection (through your telephone) you will be able to raise your hand, be unmuted, and ask questions during the session. Phone connection is preferred if you have access to a phone. WebEx Quick Reference 6 Welcome to today’s • session! Raise your hand Please use chat to “All • Participants” for questions • For technology issues only, please chat to “Host” • WebEx Technical Support: 866-569-3239 • Dial-in Info: Communicate / Join Teleconference (in Select Chat recipient menu) Enter Text 3
10/16/2014 When Chatting… 7 Please send your message to All Participants Expedition Director 8 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 on 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. 4
10/16/2014 Today’s Agenda 9 Introductions Action Period Assignment Debrief Rapid Detection & Isolation Action Period Assignment Expedition Objectives 10 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 5
10/16/2014 Schedule of Calls 11 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 Action Period Assignment Debrief 12 Assess your current process for identifying patients with C diff. Does it include: A flagging system for patients previously hospitalized with - C diff? Prompt implementation of isolation precautions for - patients suspected of C diff, pending laboratory confirmation? Prompt notification from the laboratory of results of - testing? “Assess” this process by interviewing a bedside nurse on a unit caring for C diff patient(s) What did you learn? Insights? Surprises? 6
10/16/2014 Faculty 13 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 14 Cliff McDonald, MD, is a former officer in the Epidemic Intelligence Service and is currently the Senior Advisor for Science in the Division of Healthcare Quality Promotion at the CDC. This division seeks to protect patients and healthcare personnel and promotes safety and quality in healthcare delivery systems. Examples of activities include programs for addressing antimicrobial resistance, healthcare-associated infections, and other adverse events affecting patients and healthcare workers. Dr. McDonald is an expert in Clostridium difficile , an antibiotic resistant bacterium. Dr. McDonald graduated from Northwestern University Medical School in Chicago. He completed his Internal Medicine Residency at Michigan State and an Infectious Diseases Fellowship at the University of South Alabama, following which he completed a fellowship in Medical Microbiology at Duke University. Past positions have included Associate Investigator at the National Health Research Institutes in Taiwan, where he helped develop an island-wide surveillance system for antimicrobial resistance, and Assistant Professor in the Division of Infectious Diseases at the University of Louisville, where he worked as a hospital epidemiologist in infection control. He is the author or co-author of over 100 peer-reviewed publications, is a Fellow of the American College of Physicians and the Society for Healthcare Epidemiology of America, and a member of the Infectious Diseases Society of America and American Society for Microbiology. Areas of Expertise include: C. Difficile, Drug Resistant Pathogens, and Healthcare Associated Infections To request an interview, call CDC′s Division of Media Relations at (404) 639 - 3286, or e-mail us at media@cdc.gov. 7
10/16/2014 Changing from EIA to GDH PCR Testing for CDI Brian Koll, MD, FACP, FIDSA Executive Director, Infection Control Mount Sinai Health System Professor of Medicine Icahn School of Medicine Acknowledgements Research Fellow Statistical Analysis • Jennifer Leoniak DO • David Lucido, PhD Data Collection Microbiologic Data • Jonathan Martin, MD • William Riley, PhD • Rie Ueno, MD • Aaron Etra, MD Pharmaceutical Data • Tom Jodlowski, PhD 16 8
10/16/2014 BACKGROUND ▶ Clostridium difficile (CDI) is the most commonly recognized cause of infectious diarrhea in health care settings and is one of the most common healthcare associated infections ▶ The goals of testing patients with clinical significant diarrhea (CSD) are to identify cases of Clostridium difficile infection. Cohen, S.H., Gerding, D.N., Johnson, S., Kelly, C.P., Loo, V.G., McDonald, L.C., Pepin, J., Wilcox, M.H., Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology 2010; 31 (5): 431 – 455. 17 BACKGROUND: Testing Algorithms ▶ One of the ways hospitals can decrease CDI incidence and decrease length of stay is through improved testing protocols, which can decrease spread of CDI through increased detection and more rapid implementation of infection control measures. ▶ Diagnostic testing for CDI has undergone a paradigm shift in recent years from immunoassay for toxins A and B, to the newer molecular assays or combination algorithms 18 9
10/16/2014 BACKGROUND: Performance for Testing Strategies Performance Characteristics: Results for Different Testing Strategies Approx. Cost of Testing Sensitivity Specificity Assay(s) Materials at our Facility % % ($) Toxin A/B alone 32-98.7 84-100 5.00 GDH and toxin A/B EIA 41-92 94-100 15.00 GDH/toxin A/B EIA and 68-100 97-100 15.00-30.00 molecular Molecular alone 73-100 91-100 30.00 GDH assay had lower sensitivities with specimens positive for ribotypes other than 027 19 BACKGROUND: FDA APPROVED PCR Food and Drug Administration-Approved Polymerase Chain Reaction Assays for Clostridium difficile Gene Target (s) Time (min) tcdB 75-100 tcdB 180-200 tcdB +/- tcdC 30-45 Binary toxin tcdB 60-90 tcdA tcdB 110-120 tcdC tdc C gene is found in NAP1/BI/O27 strains and is associated with increased toxin production 20 10
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