AHA/HRET HEN 2.0 PREVENTING AND DIAGNOSING C. DIFFICILE INFECTIONS: PRESERVE, PREDICT, PROTECT. December 14, :00 a.m. 12:30 p.m.

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1 AHA/HRET HEN 2.0 PREVENTING AND DIAGNOSING C. DIFFICILE INFECTIONS: PRESERVE, PREDICT, PROTECT December 14, :00 a.m. 12:30 p.m. CT 1

2 WELCOME AND INTRODUCTIONS Natalie Erb, Program Manager, HRET 11:00 11:05 2

3 AGENDA 11:00-11:05 AM Welcome and Introductions Review of platform and agenda. 11:05-11:10 AM HEN Data Update Review required outcome measure for C. difficile in HEN :10-11:25 AM Preserve and Predict: Stewarding Antibiotics and Diagnosing C. difficile Disease Describe the value to the patient and community of an antibiotic stewardship program (ASP). Provide guidance on how to create a plan to take the next steps in development of an ASP and how to develop strategies to accurately diagnose C. difficile disease while avoiding over-diagnosis. 11:25-11:40 AM Hospital Story Logansport Memorial Hospital, IN Example of CDI harm reduction in action by an HRET HEN 2.0 hospital. 11:40 AM-12:00 PM Prevent: Do Gloves Make Us Stupid? Keeping human factors in mind, describe the keys to preventing the spread of C. difficile spores between inpatients. Design approaches to optimize and monitor room cleaning effectiveness. 12:00-12:15 PM Bring it Home Discuss action steps for implementing interventions to prevent C. difficile. 12:15-12:30 PM Q&A All Natalie Erb, MPH Program Manager, HRET Rich Rodriguez Data Analyst, HRET Steve Tremain, MD Improvement Advisor, Cynosure Health Jeanette Huntoon, RN, BSN, MSM VP of Physician Network/Director of Quality Lori Sylvester, RN, BSN, CIC Infection Prevention Dan Turney, Director of Environmental Service Jackie Conrad RN, BSN, MBA Improvement Advisor, Cynosure Health Natalie Erb, MPH Program Manager, HRET 3

4 OBJECTIVES FOR TODAY Describe the value to the patient and community of an antibiotic stewardship program (ASP). Provide guidance on how to take the next steps in the development of an ASP. Develop strategies to accurately diagnose C. difficile disease while avoiding over-diagnosis. Keeping human factors in mind, describe the keys to preventing the spread of C. difficile spores between inpatients. Design approaches to optimize and monitor room cleaning effectiveness. 4

5 HEN DATA UPDATE Rich Rodriguez, Data Analyst, HRET 11:05 11:10 5

6 HEN 2.0 MEASURES Topic Data Elements HEN 2 Measure(s) Supported C. difficile C. difficile labid events (facwidein) Predicted number of C. difficile labid events* Patient days SIR* Rate of health care associated CDI Hand Hygiene Number of contacts for which hand hygiene was performed Number of contacts for which hand hygiene was indicated Hand hygiene percent adherence * Only for facilities that are using NHSN NHSN protocol can be found at: 6

7 HEN 2.0 MEASURES Confer rights to NHSN Group: HRET NHSN Group: SHA NHSN Group Baseline period: Calendar year 2013, OR Calendar year 2014 OR Jul - Sept

8 Preserve and Predict: Stewarding Antibiotics and Diagnosing C. Difficile Disease Steve Tremain, Improvement Advisor, Cynosure Health 11:10 11:25 8

9 Polling Question Please tell us who is on the call! A. Infection Preventionist B. Quality Improvement Leader C. Pharmacist D. Physician E. Front Line Staff F. Other 9

10 IMPACT OF CDI Data from population-based surveillance in ,000 annual C. diff infections 15,000 attributable deaths 80% age >65 66% health care related $1B in excess costs Lessa et al, NEJM, 372: ,

11 CDI RISK FACTORS Antibiotic exposure is the single most important risk factor Up to 85% of patients have had antibiotic exposure in the 28 days before infection Chang HT et al. Infect Control Hosp Epidemiol 2007; 28:

12 MOST COMMON REASONS FOR UNNECESSARY THERAPY 30 50% of antibiotic use is inappropriate 576 (30%) of 1,941 days of antimicrobial therapy deemed unnecessary Hecker at al, Arch Int Med, 163: ,

13 ANTIMICROBIAL STEWARDSHIP PROGRAM (ASP) Promotes appropriate use of antimicrobials by selecting the appropriate agent, dose, duration and route of administration.

14 POLLING QUESTION The following reflects the current state of my hospital s ASP: a. We have extensive experience and have impacted our antimicrobial resistance b. We have moderate experience and are making progress c. We have limited experience with an ASP d. We have no experience with an ASP 14

15 POLLING QUESTION If you answered A or B (extensive or moderate experience with an ASP), please tell us about your hospital (check all that apply): a. Community or university hospital b. Rural hospital c. Critical access hospital d. Children s hospital e. Part of a health system 15

16 ANTIBIOTIC STEWARDSHIP: DOES IT WORK? Hospital Antibiotic Stewardship Programs have been shown to: Improve antibiotic use Reduce antibiotic resistance Reduce C. difficile Improve patient outcomes Save $ 16

17 JOURNAL OF ANTIMICROBIAL CHEMOTHERAPY FEAZEL ET AL, 2014 Meta-analysis of 16 studies Stewardship programs significantly protective against C. difficile Risk ratio 0.48 ( ) Restrictive interventions most effective 17

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20 CDC Publication March 2014 Core Elements: Leadership Commitment Accountability Drug Expertise Action Tracking Reporting Education 20

21 ASP STRATEGY SELECTION Facility dependent Beds and acuity of care Dedicated personnel Funds Pharmacy support Electronic systems Laboratory support 21

22 IMPLEMENTATION TIPS The challenge is to move physician behavior Develop standards, expectations, guidelines (such as nurse-driven catheter removal) Develop process to measure feedback and have accountability to the standards and feed that back to those at the front lines 22

23 IDEAS Eliminate nonsensical combination therapy Example: You don t need dual anaerobic therapy Focus on PO/IV conversion Restrict drugs to diagnosis and location 72 hour structured time out 23

24 Messaging Don ts DON T talk about saving money DON T start hammering outliers Do s DO talk about the 4 Rights right antibiotics right patient right dose right length of time 24

25 SHEA-IDSA GUIDELINE: CDI CASE DEFINITION (2) Diarrhea ( 3 loose stools in 24 hours) Stool test positive for Clostridium difficile toxin or toxigenic Clostridium difficile OR Colonoscopic or histologic evidence of pseudomembranouscolitis 25

26 ARE WE OVER-DIAGNOSING CDI CASES? There are many causes of hospital-acquired diarrhea Many patients are admitted as carriers or acquire carrier status after admission Polymerase Chain Reaction technology (PCR) Identifies toxin-producing organism Does not identify the presence of the toxin Does not differentiate C. difficile associated disease (CDAD) from carrier 26

27 CDI TESTING DEFINITIONS / METHODS Toxin immunoassay by itself is not sensitive enough, leading to under-diagnosis PCR is highly sensitive and specific, but its predictive value is based on the chances a specific patient could have CDI, leading to 27

28 HOT OFF THE PRESS: JAMA INT MED NOV Among hospitalized adults with suspected CDI, virtually all CDI-related complications and deaths occurred in patients with positive toxin immunoassays. Patients with a positive molecular and a negative toxin immunoassay had outcomes comparable to patients without C. difficile by either method. Exclusive reliance on molecular tests without tests for toxins or host response is likely to result in overdiagnosis and overtreatment. 28

29 HOW CAN THIS BE? PCR can falsely identify the toxin producing genes as often as 50% of the time! Even when it accurately finds the genes, presence of toxin producing genes does not mean that the genes are currently producing toxins and that the patient has CDI. 29

30 POLLING QUESTION Our hospital lab routinely runs toxin immunoassays alone or in combination with PCR: A. Yes B. No C. Not sure 30

31 POLLING QUESTION A 68 year old man develops loose stools on hospital day three. A stool specimen is sent and returns + for C difficile. What actions would you take? a. Initiate contact precautions b. Investigate other reasons for diarrhea c. Contact physician to determine if clinical diagnosis of active CDI is present d. All of the above 31

32 DIAGNOSIS OF CDI PCR alone does NOT make the diagnosis of CDI case!! CDI is a CLINICAL diagnosis. Consider adding toxin immunoassays to your lab Consider the clinical setting before even ordering the test: Prior laxative Tube feeding started Other causes of loose stools 32

33 LOGANSPORT MEMORIAL HOSPITAL Jeanette Huntoon, RN, BSN, MSM VP of Physician Network/Director of Quality Lori Sylvester Infection Prevention RN, BSN, CIC Dan Turney, Director of Environmental Service Logansport, Indiana 33

34 ABOUT US Located in Logansport, IN Founded in employees 83 acute care inpatient beds County not-for-profit independent hospital Approximately 2,000 admissions per year Cares for patients in Cass County and 5 other surrounding counties 34

35 IN THE BEGINNING No standardized processes 35

36 TESTS & WHAT WE LEARNED Staff Education Nurse Driven Orders Standardized EVS Cleaning Process Collaboration with Physicians 36

37 BARRIERS & HOW WE RESOLVED No Consistency with Cleaning Process ATP (Adenosine Triphosphate) Monitoring for EVS Staff No Physician Champion Hospitalist to the Rescue Clinical Staff Working Independently Safety Rounding together 37

38 WHAT HAPPENED NEXT? 38

39 ADVICE FOR OTHERS YOU RE NEVER DONE 2 nd Q2015 Nurse didn t send stool counted for HAI per NHSN protocol 3 rd Q2015 First patient developed diarrhea on 8 th day in ICU Second patient developed loose stools on day 5 on M/S 39

40 NEXT STEPS Redesign nursing assessment to auto notify physician with specific criteria Investigate other cleaning options Started nurse/hospitalist safety huddles every day on every patient 40

41 Prevent: Do Gloves Make Us Stupid? Jackie Conrad, Improvement Advisor, Cynosure Health 11:40 12:00 41

42 Basic premise: Human beings are fallible HUMAN FACTORS 42

43 WHAT IF HANDWASHING WAS VISIBLE? 43

44 HUMAN FACTORS Factors influencing the completion of a task: Physical demands Skill demands Mental workload Team dynamics Aspects of the work environment (lighting, noise, distractions) 44

45 HUMAN FACTOR ENGINEERING Make it hard to do the wrong thing Make it easy to do the right thing 45

46 HUMAN FACTORS ENGINEERING Usability testing Test in real world conditions Understand unintended consequences Identify work arounds Forcing functions Prevents unintended or undesirable actions 46

47 HUMAN FACTORS ENGINEERING Standardization Equipment and processes Increase reliability, improve information flow, minimize cross training needs. Use of checklists Resiliency efforts Unexpected events are likely to happen detect early and mitigate before they worsen Build on insights from HROs and complex adaptive systems 47

48 THE MIGHTY GERM C. Difficile is a fastidious anaerobe Dies within 24 hours outside the colon Spores can persist for 5 months on hard surfaces Highly resistant to cleaning and disinfection C. Diff spores stick around long after symptoms 48

49 TRANSMISSION Healthcare Providers Spread C Diff Infected humans Inanimate objects 49

50 HOW HUMAN FACTORS IMPACT THE SPREAD OF CDI ENVIRONMENTAL SERVICES Human Factors Workload Time pressures Distractions Skill in mixing solutions Knowledge of cleaning and disinfection standards for C Diff Task Expectations Vigorous cleaning and disinfection of all surfaces Disinfection contact time Complex environment mix of furniture and medical equipment Availability of equipment rags, mop heads, buckets, PPE Placement of hand gel

51 HOW HUMAN FACTORS IMPACT THE SPREAD OF CDI CLINICAL STAFF Human Factors Workload Time pressures Distractions Knowledge of cleaning and disinfecting standards Beliefs about hand washing Lack of clarity in who cleans medical equipment Task Expectations Vigorous cleaning needed Disinfection contact time Complex environment - mix of furniture and medical equipment Availability and placement of PPE Placement of hand gel Availability of cleaning and containment supplies wipes, stool clean up kits, commode liners Availability of single patient use equipment

52 HOW DO YOU KNOW IT IS GOOD ENOUGH? Environmental Cleaning 52

53 SETTING A PLAN TO MONITOR Administration Infection Control Practitioner Environmental Services 53

54 THINGS TO CONSIDER Current hospital acquired infection (HAI) rates Is there a breakout or an increase in HAIs? Make it non-punitive. Assign to infection control practitioner or epidemiologist. Involve staff in developing checklists and methods of evaluation. 54

55 What method does your facility use to monitor environmental POLLING cleaning? QUESTION Choose all that apply. A. Competency evaluation of environmental services staff B. Direct observation of practices (covert) C. Swab cultures D. Apgar slide cultures E. Florescent gel F. ATP system G. Other please chat in what you do H. Don t know 55

56 LEVEL 1 PROGRAM Environmental services (ES) and infection control practitioner (ICP) partnership ICP/ES definition of expectations consistent with CDC. Clear roles in ES and other staff for cleaning high touch surfaces Structured education with ES staff Measures for monitoring competency Interventions in place to optimize terminal room cleaning and disinfection standing agenda item on the Infection Control or Quality Committee 56

57 LEVEL 2 PROGRAM Level one plus In conjunction with ES staff, objective assessment of terminal room cleaning using one or more objective methods Scheduled ongoing monitoring of terminal cleaning Results of objective monitoring and interventions to optimize terminal room cleaning are a standing agenda item on the Infection Control Committee 57

58 LEVEL 2 TESTING OPTIONS 58

59 What barriers do staff WHAT HAVE YOU LEARNED encounter? THROUGH MONITORING ENVIRONMENTAL CLEANING? What have you changed? How do you include staff? Please enter into the chat 59

60 Sample Checklist 60

61 BRING IT HOME Natalie Erb, Program Manager, HRET 12:00 12:15 61

62 PHYSICIAN LEADER ACTION ITEMS What are you going to do by next Tuesday? Find out if you have an active ASP Is it working? How are physicians responding to it? What are you going to do in the next month? Working with infection prevention, assess how you are testing for C. difficile and how you are making the diagnosis of active C. difficile disease? 62

63 UNIT-BASED TEAM ACTION ITEMS What are you going to do by next Tuesday? Assess the clarity in roles regarding who is responsible for cleaning medical equipment in isolation rooms What are you going to do in the next month? Conduct a gap analysis on tools and equipment available to decrease the microbe load in isolation rooms 63

64 HOSPITAL LEADERS ACTION ITEMS What are you going to do by next Tuesday? Become aware of the antimicrobial resistance patterns in your hospital. Is there a problem? What are you going to do in the next month? Using the CDC s Core Elements document, work with physician and pharmacy leaders to develop or enhance the ASP 64

65 PFE LEADS ACTION ITEMS What are you going to do by next Tuesday? Assess current practices and education to support patient hand sanitation What are you going to do in the next month? Invite a patient or family member to provide input in reviewing visitor isolation practices and education 65

66 THANK YOU! Find more information on our website: Questions/Comments: 66

67 RESOURCES Antibiotic Stewardship Programs Survey of Staff Attitudes Towards ASP and Current Practices, Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship, Agency for Healthcare Research and Quality, September Retrieved from The Evaluation and Research on Antimicrobial Stewardship's Effect on Clostridium difficile (ERASE C. difficile) Project, Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship, Agency for Healthcare Research and Quality, November Retrieved from Last accessed November 18, Checklist for the Core Elements of Hospital Antibiotic Stewardship Programs, Centers for Disease Control and Prevention, Retrieved from Antimicrobial Stewardship: Implementation Tools & Resources, Society of Healthcare Epidemiologists of America. Retrieved from Diagnosis Polage et al, Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era, JAMA (175): , November 1, Retrieved at Last accessed November 18,

68 RESOURCES Prevention Dubberke, E et al, Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update, infection Control and Hospital Epidemiology (35): , June Retrieved from Last accessed November 18, Guide to Preventing Clostridium difficile Infections, Association for Professionals in Infection Control and Epidemiology, February Retrieved from Reducing C. difficile Infections Toolkit, Best Practices from the GNYHA/UHF Clostridium difficile Collaborative, Greater New York Hospital Association United Hospital Fund, Retrieved from Toolkit_GNYHA.pdf Tools for Evaluating Environmental Cleaning, Healthcare Associated Infections: Facilities/Settings, Centers for Disease Control and Prevention, last updated February 25, Retrieved from Last accessed November 18,