Spores No More: A Clostridium difficile Reduction Initiative

Transcription

1 Spores No More: A Clostridium difficile Reduction Initiative Jennifer Radtke, MSN, RN, CEN, TCRN, CIC Manager Infection Prevention University of Tennessee Medical Center 1

2 Objectives Discuss the challenges Clostridium difficile infection presents to healthcare organizations and our patients Describe the initiatives implemented at UTMC to reduce hospital-onset C. diff infection Review pre- and post-implementation hospital-onset C. diff SIR and TAP data 2

3 Background 3

4 Background 4

5 Houston, We Have a Problem Mr. B: 12/31 admitted with 2 week hx of diarrhea Stool specimen ordered HD #3 C. diff specimen was not sent until HD #5 Was he on contact precautions? Results + HD # D/C d 1400 Mr. M: Admitted to Mr. B s room the next day The following day the pt was transferred to the ICU On HD #5 diagnosed with CDI 5

6 Background-Challenges Communication Environmental cleaning Testing (revealed in RCAs) Timing Appropriate specimens Laxative use 6

7 Team Membership B. McCullough Rx S. Walker Corelab J. Daniels 4S C. Allen Transport A. Groover 9E H. Bennett IP V. Burris Transport S. Sawyer 6E T. Samsel IP L. Shields RT W. Greer Rehab T. Day TSICU M. Cole Micro J. van Zyl Pathways B. Shingler NCC W. Pickel MCC S. Cusick 4H V. Turner NFS K. Boggess CVICU M. Travis Endoscopy J. Moore Endoscopy J. Beecham - Maintenance S. Galyon Pathways J. Radtke IP J. Janoyan UTH M. Rasnake IM/ID B. Shegog EVS L. Duncan - Pathology A. Cavalea Surg resident J. Brown ED R. Jensen SCM H. Shiflett IM resident 1 st Meeting: March 24,

8 What Does it Mean to Our Patients? I began considering FMT after learning of it not from any of my team of excellent physicians, but from one of my daughters, a corporate tax attorney in DC, who loves to do research for fun took our googled recipe, protocol and stack of research papers denied permission to perform FMT My husband and I performed FMT by enema, at home, in March, 2012, after one of my physicians agreed to write the order for my husband s stool test. Within 24 hours, all symptoms disappeared, and two weeks later no c. diff or toxins were detected. 8

9 Three-Pronged Approach Hand Hygiene & Contact Precautions Ordering/Testing (IT Support) Environmental Cleaning 9

10 Ordering/Testing Data on C. diff ordering 7%: >48 hours 41%: Not collected Highest volume: Monday 10

11 Ordering/Testing Solution: PowerPlan replaces order in catalog Has indication for ordering Includes an auto-discontinue order Notifies provider if laxatives have been given Education: Isolation for suspicion Implemented on June 8,

12 What is an appropriate specimen? When should a sample be sent? Laxative free for 24 hours Stool scale 6 or 7 Milkshakes, Chocolate Syrup or Frosting Bristol Stool Scale Chocolate 12

13 Powerplan Results Implemented 6/8/17 34 C. diff orders were autocancelled in one month 5 Tests were reordered 3 Neg, 1 new HA, 1 recurrent» The 2 + Cases- testing reordered the next day June-December 2017: 414 C. diff tests were automatically cancelled Averaging: 56 canceled tests per month 13

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15 Environmental Cleaning Vinegar the New Smell of Clean Oxycide Trialed August NCC, TSICU, 4S &11E EVS training Nov Implemented: Nov 29 th Sporicidal disinfectant is now used for all routine and turnover cleaning of inpatient areas 15

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18 Contact Precautions & Hand Hygiene Pink Sign Fatigue Develop new signs/color for C. diff precautions Hand hygiene campaign Discontinuation of Contact Precautions for MRSA Colonization 18

19 C. difficile and Hand Hygiene Wash with soap and water for C. diff (& infectious diarrhea) 19

20 Revised Isolation Signs Other signs (not pictured) include: Contact/Airborne Contact/Neutropenic Droplet Airborne Neutropenic Implemented: Jan

21 Contact Precautions & MRSA Organizations are moving away from using contact precautions on MRSA colonized patients. Two examples are provided below: Virginia Commonwealth University Medical Center (VCUMC): After a yearlong trial in which most patients with MRSA were maintained under standard precautions only, there was no increase in MRSA infection rates. UCLA & Santa Monica Hospital: Analysis of the first year after discontinuation of routine contact precautions for MRSA found no evidence of increased rates of recovery of these organisms. 21

22 MRSA/Contact Precautions Pilot Began on October 1, 2017 Units with the EXCELLENT hand hygiene compliance rates >90% for 6 consecutive months Results of the pilot and a proposal were presented and approved by the Infection Prevention Committee 22

23 MRSA Pilot Results 680 isolation days avoided Patients NOT placed in isolation : Total: 224 Average: 6.86 Cost avoidance: $19,006 Hospital-onset MRSA bacteremias: Pre-Pilot period: 2 Oct Jan 2018: 2 Nasal Swab Conversions (critical care) Baseline period (Aug/Sept): 2 October: 1 November: 1 December: 1 (positive on previous admission but pt was not swabbed on admission so it s hospital onset, but not a true conversion) 23

24 MRSA Colonization D/C of Contact Precautions Pilot Proposal: Discontinue requirement of contact precautions on MRSA colonized patients on units meeting the following requirements: Hand hygiene compliance 90% for 4 consecutive months Units must maintain ongoing hand hygiene compliance of > 90% If compliance drops below 90% for 2 consecutive months, contact precautions will again be required for MRSA colonized patients 24

25 Hand Hygiene Goal: Improve overall HH Compliance Challenges: Locations of sinks Room entry/exit 25

26 Effective January 1, 2018 Any observation by TJC surveyors of individual failure to perform hand hygiene in the process of patient care will be cited as a deficiency resulting in a Requirement for Improvement (RFI) under Infection Prevention and Control (IC) Standard IC , EP 2 Our New Hand Hygiene Campaign 26

27 Hand Hygiene Campaign 27

28 Antimicrobial Stewardship 28

29 Fluoroquinolone Usage 29

30 TAP & CAD Reports CAD is the number of infections we need to prevent to meeting the HHS 2020 goal for C. diff infections 30

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35 Contact Information: Jennifer Radtke Manager-Infection Prevention University of Tennessee Medical Center