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 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 2

Housekeeping Items: Chat 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. 3

Housekeeping Items: Polling 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. 4

Save the Dates 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

Polling Question 1 What best describes your role? • Infection Preventionist • MD • QI • Staff Nurse • Environmental Service Staff • Administrator • Other

Polling Question 2 What best describes your facility? • Acute Care Hospital • LTACH • Nursing Home • Other

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: (+) C. difficile test result per patient and location Prior (+) in ≤2 weeks from same pa4ent and loca4on (including across calendar months) NO YES Not LabID LabID Event Duplicate C. Event difficile test

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 Special approaches • Conduct CDC or WHO compliant • During outbreaks or hyperendemic hand hygiene when exiting the CDI, perform hand hygiene with patient ’ s room soap & water before exiting patient room with CDI • Soap & water preferentially in outbreak or hyperendemic settings • Ensure proper hand hygiene technique when using soap & water • Hand hygiene products readily available • Be aware hand hygiene adherence may decrease when soap & water is • Measure compliance 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 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 1.21* *Only value that was statistically better than others Edmonds, et al. Presented at: SHEA 2009; Abstract 43 . HAI Elimination Clostridium difficile (CDI) Infections Toolkit, Div of Healthcare Quality Promotion, CDC 2009

Contact Precautions Basic practice Special approaches • Contact Precautions for • Extend use of Contact Precautions duration of diarrhea beyond duration of diarrhea • Isolation signage • Presumptive isolation for symptomatic patients pending • Private rooms preferred confirmation of CDI • Dedicated or disposable • Implement universal glove use on noncritical medical items e.g. units with high CDI rates thermometers • Gown & gloves availability

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

Estimated # of MDRO/CDI in Next 5 Years • CDI • MRSA • CRE • MDR PA http://www.cdc.gov/vitalsigns/stop-spread/index.html

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

Systematic Approach to Prevention Antimicrobial Stewardship Early Environmental Recognition of Cleaning CDI Contact Precautions