Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship HOSPITAL IN ACTION — SUCCESSFUL STRATEGIES FOR REDUCING C. DIFF Cathy Jaco, RN, MSN, CPHQ, HACP, CPPS Objectives Mission to Care FHA HIIN 1
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship What we are all about…… Florida Hospital-Heartland Medical Center Two campuses in Southeastern Florida: Sebring (147 beds); Lake Placid (50 beds) Seasonal Patients (October-April) with average age >60+ years 1,412 Employees 285 physicians on the medical staff-23 Clinics 43,136 Emergency Room Visits- County’s busiest ER 920 Births 56% Market Share in South Florida Mission to Care FHA HIIN 2
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Creating Urgency Creating a Sense of Urgency Mission to Care FHA HIIN 3
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Establish a Sense of Urgency • February 2015, PCR Test initiated at FHHMC. This graph 1 depicts the December AHS Dashboard with 50% increase Establish a Sense of noted in Hospital-Onset C-Diff cases. Urgency • April 2016, EIA – 2 Step Test begins. • June 2016, C-diff Urgency Taskforce starts. Create the Guiding Coalition 2 Create the Guiding • Leadership commitment Coalitio n • Taskforce • Guiding principle: “zero tolerance” Mission to Care FHA HIIN 4
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship 3 Develop a Vision & Strategy Develop a Vision & Strategy • What was our Vision? • What was our Strategy? • Understand and educate on C-diff • Correct identification of patients with Hospital-Onset C-diff • Understand current practice for ordering C-diff test Infection (HO CDI) • Change the PCR test to EIA Test • Reduce over-diagnosis and over- • Understand the consequences of treatment of HO CDI higher rates of HO CDI • Better informed providers, nurses, patients “Turn Cathy Loose” 3 Strategy - Education Develop a Vision & Strategy CBL for Nurses, CNAs, Lab Presentations to Hospitalists and Poster for Units Medical Staff Mission to Care FHA HIIN 5
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Strategy -Change the Test Based on Evidence 3 Develop a Vision & Strategy The Famous Poop Patrol 4 Communicate the Change Dr. Gonzalez, CMO and Pam Stiles, Quality Liaison provide treats and laughs to nursing staff. Mission to Care FHA HIIN 6
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Education by the Poop Patrol 4 Communicate the Change • Provided at orientation and during 1:1 meetings on the units • Describes the quantity, color and consistency • Monitors by the Quality department until automatic discontinuance order finalized in the EMR Empower Broad Based Action 5 Empower Broad-Based Action • Empower Change! • Empowered Quality department to review cases and discontinue tests when there is no presence of diarrhea documented • Empowered CMO – the Head “Poopa” by Medical Executive Committee (MEC), that no repeat PCR test would be performed by lab without consulting CMO • Empowered clinicians with new knowledge Mission to Care FHA HIIN 7
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Chasing Zero! • Simple data presented at meetings with case presentation of the fall outs. 6 Number of HO-CDIFF Generate Short- Term Win s Number of HO-CDIFF 2 2 1 0 0 0 0 0 0 0 July Aug Sept Oct Nov Dec Jan Feb Mar April Consolidate Gains and Make More Changes 7 Consolidate Gains & Make More Change • EMR: Auto Cancellation of C.difficile order Mission to Care FHA HIIN 8
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Laxative Alert for Physician Orders 7 Consolidate Alert fires if the Gains & Make More Change individual entering an order for C-diff has either received a laxative in the past 24 hours or there is an active order for laxative FHHMC--Hospital-Onset Clostridium Difficile Rate March 2015 – March 2017 25 Sunday Coverage 2-Step Testing Algorithm Started (Per 10,000 Patient Days) 20 Hospital-Onset Cases C-Diff Urgency PCR Testing Started Meetings 15 "Poop ASP Patrol" 10 UV EMR Light 5 Alerts 0 Dec-16 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Jan-17 Feb-17 Mar-17 Month Mission to Care FHA HIIN 9
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship FHHMC--Hospital-Onset Clostridium Difficile SIR 2014 Q4 - 2017 Q1 Sunday Coverage Started 2.5 C. Diff Urgency … Standardized Infection Ratio 2 ASP Started NAAT “Poop Patrol” 1.5 1 UV 0.5 EMR Light 0 2015 Q1 2015 Q2 2015 Q3 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 SIR 0.921 0.916 2.308 1.738 1.467 1.488 0.684 0.154 0.17 _ Process Measures 7 Consolidate Gains & Make 120% More Change 100% 80% Axis Title 60% 40% 20% 0% Physician ASP Referral and Nurse Non-C-Diff UV Light Attendance at Antibiotic Completion of Antibiotic DC'd Cleanings (Target: Education Reduction CBL (Target: 90%) (Target: 90%) 100%) (Target: 90%) (Target: 60%) Compliance 96% 92% 78% 100% 100% Mission to Care FHA HIIN 10
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Anchor New Approaches in the Culture • Taskforce continues to meet to discuss patients with 8 Anchor New positive/negative tests (high risk) Approaches in the Culture • Celebrate success and re-evaluate opportunities for other infectious diseases (MRSA) • Evaluate UV-Light technology using cloud-based technology • Use Urgency as a mechanism for improvement Anchor New Approaches in the Culture 8 Anchor New Approaches in the Culture What’s the worst thing you can hear when you have a good idea at work? “That’s not how we do it here!” Mission to Care FHA HIIN 11
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship References • Dubberke ER. Diagnosis of Clostridium difficile infection: Treat the patient, not the test. JAMA Intern Med. Doi:10.1001/ jamainternmed .2015.4607 Published online September 8, 2015. • Kotter, J. P. (1996). Leading change. Boston, Mass., Harvard Business School Press. • Kotter, J.P., Rathgeber, H. That’s not how we do it here. Boss, Mass. Harvard Business School Press • Kotter, J. P. and D. S. Cohen (2002). The heart of change : real-life stories of how people change their organizations. Boston, Mass., Harvard Business School Press. • Polage, CR. Over-diagnosis of Clostridium difficile in the molecular test era. JAMA Intern Med. Doi.10.001/ jamainternmed .2015.4114. Published online: September 8, 2015. The impact of C.difficile infection (CDI). National Foundation for Infectious Disease • (2014). NPID.org/ C.difficile . Questions? • cathy.jaco@ahss.org Mission to Care FHA HIIN 12
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