Drilling Down to Defeat Clostridium difficile. Kathy Mathews, RN Infection Preventionist Sonoma Valley Hospital February 24, 2017

Transcription

1 Drilling Down to Defeat Clostridium difficile Kathy Mathews, RN Infection Preventionist Sonoma Valley Hospital February 24, 2017

2 Participation In This Webinar To connect to the audio portion of the webinar, dial toll-free To submit a question, click on the Chat option at the top right of the presentation. 2. The Chat panel will open. 3. Indicate that you want to send a question to the Host and Presenter. 4. Type your question in the box at the bottom of the panel. 5. Click on Send. 2

3 Meet the Presenter Kathy Mathews is an infection preventionist (IP) at Sonoma Valley Hospital, and has been working in the field of Infection Control for more than 20 years. She is a member of the Association of Practitioners in Infection Control (APIC). Kathy has co-authored articles, presented conference posters, and has been a featured speaker for media events and professional conferences over the past several years. Most notably, in 2016 Kathy received first place for Clinical Performance Improvement for her Sonoma Valley Hospital PI Poster Presentation, Drilling Down to Defeat C. difficile. 3

4 Sonoma Valley Hospital 4

5 What s Going On? C. diff rates continue to rise in California and U.S. National Healthcare Safety Network (NHSN) benchmarks for other healthcare-associated infections (HAIs) continue to drop (e.g., central line-associated bloodstream infections [CLABSI]) Are current best practices for C. diff prevention enough? Evolution of Antimicrobial Stewardship Program (ASP) and C. diff 5

6 Telemedicine ID Program January 2007 inpatient Telemedicine ID Program implemented: Infectious disease consultations/education Empiric antibiotic guidelines based on antibiogram Consultant to the IP, microbiology, and pharmacy departments Development, implementation, and oversight of the ASP 6

7 Telemedicine 2 U 7

8 ASP Findings The ASP committee initially identified Fluoroquinolone and Piperacillin/tazobactam were overused in the hospital Fluoroquinolones were overused for cystitis and community acquired pneumonia Piperacillin/tazobactam was being overused in a variety of patients 8

9 ASP Changes FLOURO/PIP TAZO Use, Flouroquinolone pharmacy charges 2008: $10, : $2,359 77% reduction Piperacillin/tazobactam 2008: $51, : $14,624 72% reduction 9

10 Antimicrobial Stewardship and $ 10

11 Antibiotic Outliers Feb 2016 Single patient on extended outpatient Daptomycin therapy May 2016 Single patient on 4 weeks Daptomycin therapy as outpatient 11

12 PI Project Goals Reduce the number of patients that get hospital onset C. diff by 50% Reduce the Sonoma Valley Hospital C. diff rate below benchmark Reduce the cost associated with C. diff by 50% 12

13 PI Project Action Items Physician education and computerized physician order entry (CPOE) Emergency department s role Patient education re: antibiotics and proton pump inhibitors (PPIs) Ensure 90% of patients on antibiotics get probiotics Revise environmental services (EVS) practices 13

14 Back to Square One Drill down after setbacks Reassess IP measures hand washing timely and consistent isolation environmental disinfection ASP PPIs Lessons learned 14

15 Action Items High Five for Hand Hygiene Campaign Revise C. diff testing threshold Revise contact/enteric precautions 15

16 High Five for Hand Hygiene Campaign 16

17 120% Hand Hygiene Compliance Pre- and Post-High Five Campaign 100% 80% 60% 40% 20% 0% Compliance 17

18 Cochrane Report May 31, studies, 4,213 participants When probiotics are given with antibiotics they reduce the risk of developing C. diff by 64% Probiotics reduce the risk of side effects of antibiotics Cramping Nausea Fever Soft stools Flatulence Taste disturbances 18

19 CPOE Promotes Probiotic Use Educate Physicians (Probiotics/PPIs) Admission order sets contain option for live culture yogurt (LCY) for patients receiving antibiotics, in the Diet section. Dietician educates, daily rounds. All antimicrobial order sets have an option for LCY and/or Saccharomyces-lactobaccilus capsules (Diff-Stat) 942 mg. every day. Continue probiotics until 2 weeks post-antibiotic therapy 19

20 Probiotic + PPI Education Physicians change proton pump inhibitor (PPI) to H2 blocker or discontinue PPI whenever possible. Pharmacy alerts nutrition services of all patients with antibiotics ordered every day. Nutrition services visits patients, provides literature on the benefit of probiotics. Nurses encourage patients to consume live culture yogurt. Nurses review discharge instructions regarding probiotics and information about PPIs. 20

21 Probiotics/Live CX Yogurt + Antibiotics DATE OF AUDIT # OF PATIENTS PRESCRIBED ANTIBIOTICS # OF PATIENTS TAKING LCY AND/OR PROBIOTICS COMPLIANCE RATE June % August % February % 21

22 PPIs Nexium Prilosec Protonix 22

23 FDA Safety Communication 2/2012 U.S. FDA notice: PPIs may be associated with increased risk of C. diff-associated diarrhea Factors that predispose: Advanced age Broad spectrum antibiotic Certain chronic medical conditions Does over-the-counter (OTC) lead to overuse (recommendation is 14 days/3x year)? Possible increased risk of fracture of hip, wrist, and spine with overuse 23

24 Action Items Rapid diagnosis of C. diff and empiric contact/enteric precautions 3 diarrhea stools in 24 hours require nurse to MD communication and testing for C. diff Bleach for daily and terminal cleaning Hand washing instead of alcohol hand sanitizer Ultra violet (UV) disinfection following terminal cleaning 24

25 Test and Isolate 25

26 Pulsed Xenon Ultraviolet (UV) Light Bleach and UV disinfection reduces risk. UV lowers environmental C. diff contamination in patient rooms. 26

27 C. diff Infections Acute SNF Acute + SNF

28 C. diff Rates Acute SNF 10 Acute + SNF

29 C. diff Prevention Saves $$$$ $569,936 C. diff Cases $427,452 $142,484 savings $213,726 $356,210 savings Cases $498,694 = 2 years savings $35,621 = average cost for a single in-patient C. diff (6) 29

30 Final Thoughts Skilled nursing facility (SNF) sustained success Reducing risk in acute-care remains challenging Opportunities to improve rely on antimicrobial stewardship, physician and patient education Public health department s role Patient awareness 30

31 References Johnston BC, Ma SS, Goldenberg JZ, Thorlund K, Vandvik PO, Loeb M, Guyatt GH. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med Dec 18;157(12): Friedman G. The role of probiotics in the prevention and treatment of antibiotic-associated diarrhea and Clostridium difficile colitis. Gastroenterol Clin North Am Dec;41(4): doi: /j.gtc Epub 2012 Sep 28. Stuart H. Cohen, MD; Dale N. Gerding, MD; Stuart Johnson, MD; Ciaran P. Kelly, MD; Vivian G. Loo, MD; L. CliffordMcDonald, MD; Jacques Pepin, MD; Mark H. Wilcox, MD. 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, may 2010, vol. 31, no. 5 Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Healthcare Infection Control, Practices Advisory Committee (HICPAC), Palli S, et al "Cost drivers associated with Clostridium difficile infection in a hospital setting" ASHP 2012; Abstract Levin J, Riley L, Parrish C, English D, Ahn S. The effect of portable pulsed xenon ultraviolet light after terminal cleaning on hospital-associated Clostridium difficile infection in a community hospital. American Journal of Infection Control. 41 (2013)

32 Thank you! Kathy Mathews

33 For continuing education credit (1), please complete the evaluation at: If you registered online for this event, you will also receive the link via . A recording of today s session will be available at: (Click on today s event date to access the recording link) 33