10/16/2014 July 23, 2014 These presenters have nothing to disclose IHI Expedition Reducing Clostridium difficile Infections Session 3: Symptom Recognition, Precautions, and the Role of the Environment Brian Koll, MD Carolyn Gould, MD Diane Jacobsen MPH, CPHQ 2 Expedition Coordinator 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 on 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 organization’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. 1
10/16/2014 3 Audio Broadcast 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. 4 Phone Connection (Preferred) 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. 6 WebEx Quick Reference Welcome to today’s • Raise your hand session! 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 8 Expedition Director 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 Symptom Recognition, Precautions, and the Role of the Environment Action Period Assignment 10 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 5
10/16/2014 11 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 12 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? 6
10/16/2014 13 Faculty 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. 14 Faculty 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. 7
10/16/2014 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 of Medicine Tiered Approach Hand hygiene 1. Contact precautions 2. Sign placement 3. PPE readily available 4. and used Dedicated rectal 5. thermometers 16 8
10/16/2014 Tiered Approach Patient placement 6. Commodes 7. Environmental 8. cleaning protocols Chlorhexidine bathing 9. 17 Tiered Approach 10. Antibiotic stewardship 11. Pharmaceutical stewardship 18 9
10/16/2014 Begins with Leadership • Accountability • Link infection prevention with organizational strategy and resources • Link a culture of safety to outcomes • Engage and facilitate teamwork • Goal setting and measuring and assessing effectiveness 19 Begins with Leadership ▶ All Formal Authority Positions – Chairs, Chiefs, Managers, Directors, Supervisors ▶ All Physicians ▶ Informal Leaders 20 10
10/16/2014 Begins with Those on the Front Line 21 Begins with Diarrhea 22 11
10/16/2014 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 23 Begins with Those on the Front Line Ownership 24 12
10/16/2014 MDRO Infection Prevention Bundles 2011 – 2013 100 90 Compliance Rate % 80 70 60 50 MSBI 40 MSBIB 30 20 J2011 M M J S N J2012 M M J S N J2013 M M A O D Time 25 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 13
10/16/2014 Environmental Contamination 27 Environmental Contamination 28 14
10/16/2014 Environmental Disinfection Percentage of positive environmental cultures before and after housekeeping cleaning and after research team disinfection with 10% bleach. (9 rooms) Eckstein et al. BMC Infectious Diseases 2007 7:61 Impact of Environmental Disinfection Quaternary 10% bleach Quaternary ammonium ammonium 8.6* 3.3* 8.1* *cases per 1000 pt-days Mayfield JL. Clin Infect Dis 2000;31:995-1000 15
10/16/2014 Monitoring of Environmental Cleaning 31 Begins with Those on the Front Line Ownership 32 16
10/16/2014 Environmental Cleaning Ownership by the Department 90 80 70 60 50 Cleaning Compliance Rate 40 EVS 30 IC 20 10 0 2011 2012H1 2012H2 2013Q1 33 A Picture Says One Thousand Words 34 17
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