Preventing Hospital Acquired Infections: Clostridium difficile

Transcription

1 Washington State Hospital Association Safe Table Preventing Hospital Acquired Infections: Clostridium difficile January 31, 2017 Lucia Austin-Gil, RN Jessica Symank, RN

2 2017 Infections Catheter Associated Urinary Tract Infections Central Line Associated Blood Stream Infections Surgical Site Infections VAE/VAP/IVAC Sepsis CDI Nursing Care Falls Pressure Ulcers Venous Thromboembolism Early Elective Delivery Safe Delivery C-Section Rate Episiotomy Inductions Medications Anticoagulants Hyperglycemic Opioid Antimicrobial Stewardship General Care and Staff Immunizations Radiation Worker Safety Readmissions

3 Partnership for Patients 20% reduction in all-cause harm 12% reduction readmissions By September, 2019

4 Alaska Driven - Learning With Others 4

5 CDI 8.2% increase in Clostridium difficile infection.

6 CDI prevalence In 2011, study identified 453,000 cases of C. difficile infection resulting in 29,000 deaths. Most CDI are hospital-acquired, but community-acquired infection has increased dramatically last 10 years, may account for up to 1/3 new cases. While 50 percent of infections happen in people younger than 65, infections occurring in the elderly are particularly devastating with a mortality rate of 90 percent. Expenditures associated with CDI increased by estimates of up to $4.8 billion annually. Lessa, F. et. Al.; Burden of Clostridium difficile Infection in the United States. N Engl J Med 372; 9. February 26, 2015.

7 Risk Factors for CDI Antibiotic therapy most important Ampicillin, cephalosporins, clindamycin, and fluoroquinolones most frequently associated with infection. Advanced age Prolonged stay in healthcare facility High severity of illness Poor standards of environmental cleanliness Inflammatory bowel disease Gastrointestinal surgery Gastric acid suppression Use of Proton Pump Inhibitors (PPIs) Immunosuppression

8 Outcome Measure Definition Data Definition CDI Number of lab confirmed hospital acquired C-Diff cases per 10,000 patient days (NHSN) Numerator: Number of hospital acquired lab confirmed C- diff cases Denominator: Number of patient days

9 Process Measures Measurement Process Numerator Denominator Hand Hygiene Percent compliance with CDC/WHO recommended guidelines for hand hygiene using soap and water. Hand Hygiene Performed Total number of observed opportunities for hand hygiene in which hand hygiene was performed with soap and water by Health Care Worker (HCW). Hand Hygiene Indicated Total number of observed opportunities for hand hygiene with soap and water by a HCW. Contact Precautions Environmental Cleaning Percent adherence to Contact Enteric Precautions PPE requirements, i.e. Gown and Gloves Use as Part of Contact Precautions. Achieve 95% adherence to environmental cleaning (daily and terminal) protocols. PPE/Gown and Gloves Used Total number of observed contacts between a HCW and a patient or inanimate objects on Transmissionbased Contact Enteric Precautions for which gown and gloves had been donned appropriately prior to the contact. Total number of observed opportunities in which adherence with an environmental cleaning protocol was performed, using checklist, observations, fluorescent gel, cultures or ATP. PPE/Gown and Gloves Indicated Total number of observed contacts between a HCW and a patient on Transmission-based Contact Enteric Precautions or inanimate objects and gown and gloves were indicated. Total number of opportunities for adherence with an environmental cleaning protocol were indicated.

10 CDI Safety Action Bundle

11 CDI Prevention Toolkit

12 CDI Prevention Toolkit

13 C. difficile Prevention Effort Leadership Support and Champions Multidisciplinary Task Force Members Infection Prevention Team Physicians Nurses Pharmacists Transport Environmental Services Information Technology Create the C diff Bundle CHECKLIST Presented at Washington State Hospital Association Safe Table October 20, 2015

14 Antimicrobial Stewardship Goals Reducing Resistant Organisms Goal Reduce Clostridium difficile by 20% across our region. Antimicrobial Stewardship Programs in every hospital and health system. Reduce antimicrobial use in select antibiotics. Create vehicle to collaborate within communities to optimize antibiotics usage.

15 Antimicrobial Stewardship (ASP) Initiative Three Tiers All hospitals and health systems will have an Antimicrobial Stewardship Program

16 Early Rapid Testing and Diagnosis Watery diarrhea or loose stools are the best specimen for the diagnosis of C. difficile associated diarrhea. Please refer to Bristol Stool Chart (use types 6-7). To test appropriately and not over or under diagnose CDI, it is important to understand the distinction between a potential carrier and true CDI disease by paying close attention to key risk factors in the patient s history.

17 Early Rapid Testing and Diagnosis Carrier individuals may shed C. difficile in their stool but do not have diarrhea. Studies reveal up to 20-30% of hospitalized patients may be carriers. These individuals may spread spores into the environment at lower concentrations than patients with diarrhea. C. difficile diarrhea clinically significant diarrhea is defined as 3 loose stools in a 24 hour period, 2 hours to 2 months after use of antibiotics and frequently including abdominal cramps and pain. C. difficile is associated with 25-30% of antibiotic-diarrhea related cases.

18 Early Rapid Testing and Diagnosis

19 C. diff Testing and Diagnosis

20 Interventions Test only patients with clinically significant diarrhea which is 3 unformed, loose stools in 24 hours. Diagnosis does not require 3 unformed stools in 24 hours in hospital. Review history pre-admit. Use a nurse driven protocol to trigger C. difficile testing, such as a diarrhea decision tree. The PCR test is superior to enzyme immunoassay (EIA) for detection of toxins A and B. EIA as a stand-alone test is discouraged. It is clinically reasonable to use NAAT or PCR testing alone, although this practice may over diagnose. There are alternative methods to consider, using various algorithms to describe the process.

21 Interventions Do not retest unless there is a strong clinical suspicion after the first test. Yield for retesting after one week is very low in general. Do not repeat testing during the same episode of diarrhea for confirmed CDI patients (e.g., electronic flag). Clinical judgment is always required in conjunction with test results to diagnose CDI accurately. Implement an alert system to immediately notify the Infection Prevention team and patient provider of any newly identified cases from the lab. Implement hard stops to prevent testing of solid stools and repeat testing of a patient. Ensure the lab will reject such samples.

22 Interventions Do not test for cure, as most patients who are clinically cured with treatment will continue to have C. difficile in their stool for weeks. Ensure timely communication of CDI test results to the patient care unit, facility, provider, infection prevention, patient and family

23 Prevention of CDI Isolation and Barrier Precautions Patients with known or suspected CDI should be isolated in single room, or co-horted. Health care workers should wear gloves, gowns and wash hands with soap and water (alcohol based gels are not sporicidal). Use dedicated equipment. Viable C. difficile spores have been found on the hands and stethoscopes of health care workers, bedding, telephones, in bathrooms and on bedside furniture. Spores can survive for up to 5 months. Development of nursing protocols to facilitate Early Isolation and testing.

24 Prevention of CDI Contact Enteric Precautions

25 Attention All Staff: Wash hands with soap and water after contact with patient or items in patient s room. Thank you. Presented at Washington State Hospital Association Safe Table October 20, 2015

26 Strict Cleaning and Disinfection of Equipment and Environment Direct Observation Swab Cultures Agar Slide Cultures Fluorescent Gel ATP System The hospital environment is a significant contributor to the onset of CDI as C. difficile spores can survive on surfaces for as long as 5 months. C. difficile spores were identified in 49 per cent of inpatient rooms occupied by those diagnosed with C. difficile and in 29 percent of asymptomatic carrier rooms.

27 Interventions Build collaborative relationships between Environmental Services (EVS), Infection Prevention and hospital leadership. Educate EVS staff about CDI, including pathophysiology and symptoms, and describe what the health care team is doing to prevent infection and the critical role of EVS in infection prevention. Educate EVS staff frequently and ensure team understands: Where and when specific cleaning solutions should be used; The frequency of cleaning required; and The amount of contact time for effectiveness.

28 Interventions Perform environmental decontamination or rooms of patients with CDI using sodium hypochlorite diluted 1:10 with water or other Environmental Protection Agency (EPA) registered sporicidal cleaning agent. Consider the use of audible timers to ensure effective contact time with the appropriate cleaning solution. Create cleaning protocols and job aides for Environmental Services Staff to increase reliability. Develop checklists to use when training in and evaluating cleaning practices. Directly observe room cleaning and provide immediate feedback, recommendations and recognition to Environmental Services Staff.

29 Prevention of CDI Environmental Cleaning Use of chlorine-containing agents (at least 5,000 ppm available chlorine) for environmental contamination, especially in outbreak areas Bleach wipes Daily bleach wipe of high touch surfaces Terminal clean with bleach High Touch Investigational Kit Spray environment with substance not visible in normal light ( Glo Germ ) Have environmental services clean the room Then return with UV light to reveal missed/poor cleaning (educational, not punitive) Presented at Washington State Hospital Association Safe Table October 20, 2015

30 Prevention of CDI Environmental Cleaning Because C. difficile spores resist killing by usual hospital disinfectants, an Environmental Protection Agency registered disinfectant with a C. difficile sporicidal label claim should be used to augment thorough physical cleaning. McDonald, C et. Al: Vital Signs: Preventing Clostridium difficile Infections MMWR. 2012; 61:

31 Approved C. diff Cleaning Agents

32 Interventions Evaluate and define equipment and disinfection procedures to ensure staff effectively understand assignments and can fulfill cleaning responsibilities (for example, who, what, how, when ). Ensure cleaning materials are readily available to impact cleaning needs. Utilize a recognizable sign or visual cue to communicate that a piece of equipment has been cleaned e.g. sticker or paper sign.

33 Interventions To prevent privacy curtain contamination, attach plastic, disposable shields. Evaluate effectiveness of environmental cleaning through direct observation, swab cultures, agar slide cultures, fluorescent markers or ATP (adenosine triphosphate) bioluminescence. Include terminal room cleaning test results as standing agenda items on Infection Prevention and Board Quality Committee agendas.

34 Environmental Cleaning Checklist

35 Prevention of CDI Environmental Cleaning Environmental Disinfection Terminal Cleaning Resource Neutral Rupp ME, Adler A, Schellen M, Abstract 203 Fifth Decennial Slide Courtesy of Dr. Carling

36 C. difficile Prevention and Reduction Core Strategies Implement a robust Antimicrobial Stewardship Program (ASP) Early Rapid Testing and Diagnosis Immediate isolation and contact precautions upon recognition of diarrhea Effective hand hygiene using soap and water Strict cleaning/disinfection with bleach product/hypochlorite based solution for daily and terminal cleaning of equipment and environment Education about CDI reduction: Healthcare personnel, environmental services, administration, and patients/families Supplemental Strategies Contact precautions beyond duration of diarrhea up until discharge from hospital Presumptive isolation and contact precautions pending testing results Soap and water rather than hand sanitizers innovative methods used for monitoring hand hygiene Universal gloving on units with high CDI rates Test new methods for monitoring environmental cleaning Implementing new testing methods (e.g., PCR testing) Partner with receiving facilities (Skilled Nursing) to reduce CDI

37 Questions?