Reaching Across the Continuum of Care to Decrease CDI Events - - PowerPoint PPT Presentation

Reaching Across the Continuum of Care to Decrease CDI Events

Objectives: CDI Prevention Overview

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During this Webinar you will learn how to:

• Discuss trends in CDI rates
• Identify potential members of CDI Prevention Team
• Outline best practices for CDI prevention

Housekeeping Items: Chat

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To ensure maximum sound quality, participant lines have been muted; however we welcome ALL questions and comments via the chat board on the right hand side of your screen. To submit questions or comments:

• Use WebEx chat – send messages to the panelists or all

participants using the chat feature drop down menu.

Housekeeping Items: Polling

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During today’s presentation you may be asked to participate in some polling

• questions. These questions will come up on the right side of your screen.

When you do answer a polling question, be sure to click the submit button so we can record your answer.

Dates Topic

May 3, 2016 @ 10:00 am CST Early Detection / Appropriate Testing / LTC Facilities and Continuum of Care June 7, 2016 @ 10:00 am CST Isolation / Contact Precautions / Hand Hygiene July 12, 2016 @ 10:00 am CST Environmental Cleaning August 2, 2016 @ 10:00 am CST Antibiotic Stewardship

Save the Dates

Polling Question 1

What best describes your role?

• Infection Preventionist
• MD
• QI
• Staff Nurse
• Environmental Service Staff
• Administrator
• Other

What best describes your facility?

• Acute Care Hospital
• LTACH
• Nursing Home
• Other

Polling Question 2

Beyond CDI Basic Prevention Strategies; Reaching Across the Continuum of Care to Decrease CDI Events

Tennessee Department of Health and atom Alliance Webinar Series Learning Session 1 April 5, 2016

Introductions

Eric Sullivan, RN, MSN Clinical Quality Improvement Specialist, atom Alliance Patricia Lawson, RN, MS, MPH Public Health Nurse Consultant Rebecca Meyer, MPH Epidemiologist *Nothing to disclose / no conflicts of interest

CDI

• Spore forming anaerobic bacterium
• Not normal intestinal bacterium (flora)
• Spectrum of Disease
• Simple diarrhea
• Pseudomembranous colitis
• Toxic megacolon and

perforations of the colon

• Sepsis and death
• Development of CDI requires 2 steps
• Exposure to antibiotics result in vulnerability
• Acquisition of organism via fecal-oral route

(transmission)

The Impact of C-diff in US

• $6,000 to $9,000 estimated hospital cost per infection
• $1.8 billion estimated cost per year
• 94% of C-diff infections are connected with getting medical care
• Increased length of hospital stay (2.3-12 days)
• 29,000 deaths within 30 days annually (at least half attributable)
• Colectomies (0.3-1.3% in endemic periods; 1.6-6.2% in epidemic

periods)

• 83,000 recurrences

Patient Safety Summit 2014; Infect Dis Clin N Am 2015;29(1): 123-34; MMWR Mar 9, 2012/61(09);157-162

Burden of Clostridium difficile Infection in United States

Epidemic Strain of Clostridium difficile

• BI/NAP2/027, toxinotype III
• Epidemic since 2000
• more severe disease & increased mortality
• More virulent
• Increased toxin A and B production
• Production of additional toxin - binary toxin
• Resistant to commonly used class of antibiotics – fluroquinolones

Antibiotic Resistance Threats in US 2013 Hazard Level - Urgent

• Clostridium difficile
• Carbapenem-resistant Enterobacteriaceae (CRE)
• Drug-resistant Neisseria gonorrhoeae

What are patient risk factors?

• Antibiotic exposure
• Proton pump inhibitors
• Older Age
• Immunocompromising conditions
• Inflammatory bowel disease and other

serious underlying conditions

• GI surgery or manipulation
• Previous hospitalization and residence in

LTCF

CDI Transmission

• Clostridium difficile shed in feces
• Environmental surfaces, devices, or materials (e.g. commodes,

bathing tubs, and electronic rectal thermometers) can serve as reservoir for C difficile spores

• C difficile spores are transferred to and between patients mainly

via hands of healthcare workers who have touched a contaminated surface or item

Peggy Lillis Foundation: CDI Patient Story

Tennessee CDI Epidemiology

NHSN LabID Event CDI Reporting

LabID Event: A toxin-positive / toxin-producing C difficile stool specimen for a patient in a location with no prior C diff specimen reported within 14 days for the patient & location, and having a full 14-day interval with no toxin-positive C diff stool specimen identified by the lab since the prior reported C difficile LabID Event.

• C. difficile Test Result Algorithm for Laboratory Identified (LabID) Events:

NO YES

(+) C. difficile test result per patient and location Prior (+) in ≤2 weeks from same pa4ent and loca4on (including across calendar months) LabID Event Duplicate C. difficile test Not LabID Event

CDI HO-SIR All TN Acute Care Hospitals

CDI HO-SIR Acute Care Hospitals by Grand Division

CDI CO Rate by Grand Division

State and National Goals for C difficile Prevention

• National target
• Reduce facility-onset CDI in facility-wide
• health care
• Baseline: 1.0 SIR* (2010-2011)
• 2013 Target: 30% reduction or 0.70 SIR
• 10% decrease in hospital onset (2011- 2013)
• Proposed 2020 Target 30% reduction from 2015 baseline
• State plan
• Expand CDI prevention collaborative activities to
• enhance communication between acute & long-term care

facilities, share best practices, and reduce healthcare and community onset CDI

• *The standardized infection ratio (SIR) is a summary measure used to

track healthcare-associated infections (HAIs) at a national, state, or local level over time. The SIR adjusts for patients of varying risk within each

• facility. Data source: NHSN

Testing and Early Detection

Testing for CDI

• Test only patients with clinically significant diarrhea
• Common testing methods

– Enzyme immunoassay (EIA) for toxins A & B – Nucleic acid amplification test (NAAT) e.g. PCR (polymerase chain reaction) – Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)

• Inappropriate testing

– Test for cure – Testing when no diarrhea present – Testing with other known causes of diarrhea e.g. laxative – Duplicate stools e.g. within 7 days if negative

Contact Precautions & Hand Hygiene

Hand Hygiene

Basic practice

• Conduct CDC or WHO compliant

hand hygiene when exiting the patient’s room

• Soap & water preferentially in
• utbreak or hyperendemic settings
• Hand hygiene products readily

available

• Measure compliance

Special approaches

• During outbreaks or hyperendemic

CDI, perform hand hygiene with soap & water before exiting patient room with CDI

• Ensure proper hand hygiene

technique when using soap & water

• Be aware hand hygiene adherence

may decrease when soap & water is the preferred method

• If compliance inadequate conduct

interventions to improve HH compliance/technique

SHEA/IDSA Practice Recommendations Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update

Hand Hygiene cont.

Since spores may be difficult to remove from hands even with hand washing, adherence to glove use, and Contact Precautions in general, should be emphasized for preventing C difficile transmission via the hands of healthcare workers

HAI Elimination Clostridium difficile (CDI) Infections Toolkit, Div of Healthcare Quality Promotion, CDC 2009

Product Log 10 Reduction Tap Water 0.76 4% CHG antimicrobial hand wash 0.77 Non-antimicrobial hand wash 0.78 Non-antimicrobial body wash 0.86 0.3% triclosan antimicrobial hand wash 0.99 Heavy duty hand cleaner used in manufacturing environments *Only value that was statistically better than

• thers

1.21*

Edmonds, et al. Presented at: SHEA 2009; Abstract 43.

Contact Precautions

Basic practice

• Contact Precautions for

duration of diarrhea

• Isolation signage
• Private rooms preferred
• Dedicated or disposable

noncritical medical items e.g. thermometers

• Gown & gloves availability

Special approaches

• Extend use of Contact Precautions

beyond duration of diarrhea

• Presumptive isolation for

symptomatic patients pending confirmation of CDI

• Implement universal glove use on

units with high CDI rates

SHEA Compendium of Strategies to Prevent CDI – 2014 Updates

• Section 3 Updates

(Background-Strategies to Prevent CDI)

Contact Precautions sign: English AND Spanish

A Systematic Approach to Prevention

• CDI
• MRSA
• CRE
• MDR PA

http://www.cdc.gov/vitalsigns/stop-spread/index.html

Estimated # of MDRO/CDI in Next 5 Years

Benefit of Coordinated Approach in Decreasing CDI

• Common approach

(status quo)

• Independent efforts
• Coordinated approach

http://www.cdc.gov/vitalsigns/pdf/2015-08-vitalsigns.pdf MMWR Morb Mortal Wkly Rep. 2012;61(9):157-62; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a4.htm?s_cid=mm6430a4_w

Antimicrobial Stewardship Environmental Cleaning Contact Precautions Early Recognition of CDI

Systematic Approach to Prevention

Communication & Team Building Tools

• TeamSTEPPS

Teamwork skills:

• 1. Leadership
• 2. Communication
• 3. Situation monitoring
• 4. Mutual support

Enhance Teamwork Outcomes

Qsource CDI Toolkit A Healthcare Professional’s Guide to Preventing CDIs;

http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html

Polling Question 3

Does your facility have a multi-disciplinary team focused on CDI prevention?

• Yes, we meet on a routine basis.
• Yes, but we need to reconvene.
• No, but we have started to form a team.
• We have no plans at this time.

CDI Team Members

• Frontline Staff
• MD (CMO,

Hospitalist, ID)

• Environmental

Services

• Nurse / Staff

Educators

• Executive Leaders
• Case Managers
• IP
• QI
• Pharmacy
• Lab
• Nurse Manager

http://www.ahrq.gov/professionals/quality-patient-safety/cusp/index.html

Antibiotic Stewardship

Antimicrobial Use in Tennessee

• Highest antimicrobial use

prevalence in hospitalized patients among 10 Emerging Infections Program sites

• Antibiotic exposure is the

single most important risk factor for development of Clostridium difficile

Core Elements for Antibiotic Stewardship Programs

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Core Elements for Antibiotic Stewardship Programs

• Leadership commitment from administration
• Single leader responsible for outcomes
• Single pharmacy leader
• Antibiotic use tracking
• Regular reporting on antibiotic use and resistance
• Educating providers on use and resistance
• Specific improvement interventions

% Hospitals with Antimicrobial Stewardship Programs, with all 7 Core Elements, 2014

http://www.cdc.gov/media/images/dpk/2015/dpk-antibiotics-week/img3.pdf

National: 39.2% Goal: 100% by 2020

Core Elements: TN vs US (national), 2014

Infrastructure Implementation

Antimicrobial Stewardship Programs in TN

TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1 30% 20% 36% 22% 35% 30% 31% 45% 10%

All 7 core Elements

Environmental Cleaning

C difficile in the Environment

• Survival of Spores

– Spores survive for up to 5 months

• Transmission Mechanisms in the Environment

Diagram adapted from Rutala WA, In: “SHEA Practical Healthcare Epidemiology” 3rd ed, 2010

CDI patient or environmental reservoir Animate surfaces (principally HCW hands) Inanimate surfaces: environmental surfaces & medical equipment Susceptible host (Colonization or Infection)

Interruption via Handwashing/ glove use Interruption via cleaning / disinfection

C difficile Spores EPA-Registered Products

List K: EPA’s Registered Antimicrobials Products Effective Against C difficile spores, April 2014 http://www.epa.gov/sites/production/files/2015-09/documents/ list_k_clostridium.pdf Most are bleach based products some have other active ingredients e.g. hydrogen peroxide, peroxyacetic acid, or silver

http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental- Cleaning.html

Environmental Cleaning Checklist

6 Key Components of Prevention

• Prescribe and use antibiotics carefully
• Focus on an early and reliable diagnosis
• Isolate patients immediately
• Wear gown and gloves 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

Prevention of Clostridium difficile Infection, Carolyn Gould, MD, Div of Healthcare Quality Promotion, CDC, Natl Foundation for Infectious Diseases Webinar 2015; cdc.gov/mmwr/preview/mmwrhtml/mm6109

TN CDI Prevention Collaborative

Dates Topic

May 3, 2016 @ 10:00 am CST Early Detection / Appropriate Testing / LTC Facilities and Continuum of Care June 7, 2016 @ 10:00 am CST Isolation / Contact Precautions / Hand Hygiene July 12, 2016 @ 10:00 am CST Environmental Cleaning August 2, 2016 @ 10:00 am CST Antibiotic Stewardship

CDI Prevention Resources

• http://nursingworld.org/psjustculture
• Road Map to a Comprehensive Clostridium difficile Infection (CDI) Prevention Program
• APIC Guide to Preventing Clostridium difficile Infections
• APIC Guide to Hand Hygiene Programs for Infection Prevention
• SHEA/IDSA Practice Recommendation Strategies to Prevent Clostridium difficile Infections in

Acute Care Hospitals: 2014 Update

• CDC/FDA Health Update about the Immediate Need for Healthcare Facilities to Review

Procedures for Cleaning, Disinfecting, and Sterilizing Reusable Medical Devices; CDCHAN-00383

CDI Prevention Resources cont.

• CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf

• CDC Summary of Core Elements of Hospital Antibiotic Stewardship Programs (

http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf)

• CDC Checklist for Core Elements of Hospital Antibiotic Stewardship Programs (

http://www.cdc.gov/getsmart/healthcare/pdfs/checklist.pdf)

• Hand Hygiene Observations: http://www.qsource.org/hai-newsletter-march-2012-2/
• http://www.epa.gov/sites/production/files/2015-09/documents/list_k_clostridium.pdf
• http://www.epa.gov/pesticide-registration/guidance-efficacy-evaluation-products-sporicidal-

claims-against-clostridium#product

Thank you ! Questions?

atom Alliance HAI Contacts:

Alabama: Teresa Fox (Teresa.Fox@area-G.hcqis.org) Indiana: Mary Ellen Jackson (Mary.Jackson@area-G.hcqis.org) Kentucky: Mary Bardin (Mary.Bardin@area-g.hcqis.org) Mississippi: Trannie Murphy (Trannie.Murphy@area-g.hcqis.org) Tennessee: Eric Sullivan (esullivan@Qsource.org)

Tennessee Department of Health: Hai.health@tn.gov

Contact Information

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This material was prepared by the atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human

• Services. Content presented does not necessarily reflect CMS policy. 16.SS.TN.C1.03.005