Successful Strategies to Reduce Clostridium difficile

Successful Strategies to Reduce Clostridium difficile C.difficile, ASP and MDROs 1 February 28, 2018 3:00-4:00pm

NYS PARTNERSHIP FOR PATIENTS Agenda Topic Welcome and Introductions Clostridium difficile Prevention at Mount Sinai Beth Israel Speaker NYSPFP Staff Mount Sinai Beth Israel Medical Center Clostridium difficile Prevention Stony Brook University Hospital Hospital Questions and Discussion Tools and Resources/Next Steps Hospital Participants ASP Faculty Facilitated by NYSPFP Staff NYSPFP Staff 2

NYS PARTNERSHIP FOR PATIENTS ASP/CDI/MDRO Initiative Overview GOAL: Implement an antibiotic stewardship program (ASP) Reduce hospital multi-drug resistant organism (MDRO) infection and Clostridium difficile Infection (CDI) by 20%, from a 2015 baseline OBJECTIVES Hospitals will implement all elements of the Centers for Disease Control s (CDC) Core Elements of Antibiotic Stewardship Programs as part of the hospital s ASP program by September 2018 Reduce CDI by 20% by September 2018 Reduce MDRO infections, particularly MRSA, by 20% by September 2018 3

NYS PARTNERSHIP FOR PATIENTS C.difficile Rate Baseline 01/15 12/15: 7.56 Comparison 09/17 10/17: 4.84 Percentage change: 35.92% 4

NYS PARTNERSHIP FOR PATIENTS C.difficile SIR Baseline 01/15 12/15: 1.03 Comparison 07/17 09/17: 0.71 Percentage change: 31.05% 5

NYS PARTNERSHIP FOR PATIENTS ASP in 2017 Antibiotic Stewardship Program : Rapid Cycle Improvement Projects (Based on CDC Core Elements of Hospital Antibiotic Stewardship programs) Phase 1 Leadership commitment Accountability Drug expertise Phase 2 Actions to support optimal antibiotic use Phase 3 Tracking and monitoring antibiotic prescribing, use, and resistance Reporting information on improving antibiotic use and resistance Education of Clinicians and Patients and Families Materials for the ASP Rapid Cycle Improvement Project are available on www.nyspfp.org 6

NYS PARTNERSHIP FOR PATIENTS NYSPFP Tools and Resources for C.difficile 7 Accessed from: https://www.nyspfp.org/members/initiatives/infectionprevention/cdiff/tools.aspx

NYS PARTNERSHIP FOR PATIENTS NYSPFP Programming ASP C.difficile and MDRO April 2017 Launch of ASP Rapid Cycle Improvement Project May Nov 2017 Rapid Cycle Improvement Projects Coaching calls and on-site PM technical support February 2018 Successful strategies to reduce C.difficile Apr Nov 2018 How ASP impacts MDROs and C.difficile Emerging topics in C.difficile 8

NYS PARTNERSHIP FOR PATIENTS Polling Question o What additional topics would you like to see covered by NYSFPP in 2018? (select top 2) o More information on antibiotic stewardship (ASP) o C.difficile o VRE/CRE o C.auris o More on infection prevention practices e.g. cohorting, environmental cleaning o Other please specify

NYS PARTNERSHIP FOR PATIENTS Polling Question o What format do you find most helpful? (select top 2) o Webinars o Coaching calls o In-person regional meetings - Facilitated forums for peerto-peer sharing by hospital staff o In-person conference invited presenters to share evidence based best practices o Live webstream conferences o Panel discussion (live and web streamed) o Video conferences o Other please specify 10

Clostridium difficile Prevention Mount Sinai Beth Israel 11

Mount Sinai Beth Israel Dana Mazo, MD, MSc Hospital Epidemiologist Mount Sinai Queens Marie Moss, MPH, RN, CIC Infection Prevention February 28, 2018

Outline Summary of MSBI C. difficile prevention C. difficile testing Urine culture testing and treatment

Mount Sinai Beth Israel Teaching hospital with 756 licensed beds Founded 1889, Mount Sinai Health System 2013 Mount Sinai Downtown 2016 East Village neighborhood New York, NY Patient mix General medicine/surgery, cardiology, gender reassignment, behavioral health Medical/Surgical ICU, Cardiac Care Unit

NYS DOH Adjusted HO C. difficile Rate* 20 16 12 8 4 0 2010 2011 2012 2013 2014 2015 2016 *2015+ Cases/10,000 patient days Significantly high 2010-2014: Cases/10,000 patient days at risk Significantly low

NHSN HO C. difficile Rate* 8.0 6.0 4.0 2.0 0.0 2012 2013 2014 2015 2016 2017 *Cases/10,000 patient days

NHSN HO C. difficile SIR 0.8 0.6 0.4 0.2 0 2012 2013 2014 2015 2016 2017 2010-2011 Baseline 2015 Baseline

C. Difficile Prevention Campaign 2015 IP formal rounds of precautions adherence Enhanced monitoring of cleaning Reinforce microbiology testing rules Expanded antimicrobial stewardship program SWAT RCAs for each HO CDI Interdisciplinary Goal: conduct within 72 business hours

CDI RCAs Aug Dec 2015 17 Cases Reviewed 8 (47%) with appropriate C. difficile testing 9 (53%) with inappropriate C. difficile testing 3 with appropriate antibiotic use 5 with inappropriate antibiotic use 3 without laxative use within 48 hrs of test 6 with laxative use within 48 hrs of test

Focus on C. difficile Testing Testing algorithm EHR support MSHS initiative Pre-test interdisciplinary huddle Provider education Nursing House staff, attendings, PAs/NPs, all specialties Approval process (2017)

C. difficile Testing Algorithm No Does the patient have unexplained diarrhea (greater than 3 or more liquid stools per day)? Yes Do not send C. difficile testing if no diarrhea as it can reflect asymptomatic colonization. No Does the patient have other signs of C. difficile infection? (fever, elevated WBC, abdominal distention) Yes Important Phone Numbers: Infection Control: 212-420-2853 Infection Control Practitioner Cell: 646-477-0620 Infectious Disease: 212-420-4005 Pharm D Phone Numbers: x8445487; x8445486 Investigate other causes of diarrhea (ie. tube feeds, contrast, antibiotic associated). Discontinue orders for laxatives, stool softeners and unnecessary PPIs/antibiotics. Diarrhea persists Discuss case with Infection Control Consider sending C. difficile testing if other risk factors present (older age, antibiotic exposure, recent hospitalization, intraabdominal surgery. Multiple testing for C. difficile are not necessary as sensitivity of PCR is high. C. difficile testing is recommendedsend stool to lab immediately, especially if suspected on admission to capture community onset infection. Document indication in chart. Limit antibiotic therapy. Use Special (brown) Contact Precautions sign. Wash hands with soap and water. Use dedicated patient equipment and disinfect with bleach. Instruct patient not to use hallway bathroom and provide commode/bedpan. Educate visitors prior to entering patient s room. Contact Precautions can only be discontinued by Infection Control

Huddle Form

C. difficile Root Cause Analyses 2016 29 Cases Reviewed 21 (72%) appropriate C. difficile testing 8 (28%) inappropriate C. difficile testing Six (29%) with inappropriate antibiotic use Seven receiving laxatives One without diarrhea Three treated for asymptomatic bacteriuria

URINARY TRACT INFECTION (UTI) DIAGNOSIS & TREATMENT Does the patient have a Foley catheter? YES NO Does the patient have: NEW CVA tenderness, flank pain, acute hematuria OR Fever or rigors AND delirium WITHOUT another more likely source? Does the patient have: Dysuria, inc. frequency, CVA tenderness, suprapubic pain OR Fever AND delirium WITHOUT another more likely source? YES NO YES NO Remove catheter If still needed, replace with a new catheter and send urine culture from the new catheter prior to starting antibiotics Do NOT send urine culture Send UA and urine culture Urine culture >100,000 CFU/ml of a single organism AND UA >5 wbc Unlikely to be UTI, do NOT send urine culture Urine culture >100,000CFU/ml of a single organism NO YES YES NO UTI unlikely, do NOT treat Is the patient still symptomatic? YES NO Initiate or optimize antibiotics* UTI unlikely, do NOT treat Optimize antibiotics* Is the patient on antibiotics that treat the org. isolated? YES NO *see reverse side for treatment guidance Optimize antibiotics for UTI* Asymptomatic Bacteriuria, do NOT treat

25 Mount Sinai / Presentation Slide / December 5, 2012

UTI Stewardship Roll-Out Provider education Nursing House staff, attendings, PAs/NPs, all specialties Audit and feedback Testing, treatment, antibiotic selection Guided by Baylor Kicking CAUTI campaign B. Trautner et al. JAMA Intern Med 2015

Lessons Learned Interdisciplinary nature Hospital departments Types of providers SWAT RCAs Identify true causes Sustainability Ongoing assessment Ongoing education with feedback Synergy among initiatives

Team Effort Mount Sinai Beth Israel Infection Prevention Nursing Medical Staff Leadership Mount Sinai Health System Infection Prevention Leadership

Clostridium difficile Prevention Stony Brook University Hospital

Patient Safety Workgroup Clostridium difficile Prevention Sadia Abbasi, MD, Director of Hospitalist Medicine Francina Singh, Director of Healthcare Epidemiology Paul F. Murphy, Quality Management Practitioner

Overview of Strategy for Quality Management Our Mission: improve the lives of our patients, families, and communities, educate skilled healthcare professionals, and conduct research that expands clinical knowledge. Our Vision: Stony Brook University Hospital will be: A world-class healthcare institution, recognized for excellence in patient care, research and health care education The first choice of patients for their care and the care of their families An academic medical center that attracts educators and students with the desire and ability to provide and receive the highest quality, innovative education One of the top ranked institutions for scientific research and training. Our Vision for Quality & Safety of Care: We will be a Top Decile performer within 3 Years Strategic Vectors Clinical Outcomes Patient Safety Patient Experience Top Decile Outcomes Zero Preventable Harm Best Place to Receive Care Physician Engagement Technology Foundational Enablers Throughput Optimization Organization & Staffing Culture Physician Driven Technology No Wasted Time Quality Management Culture of Excellence Quality Program Accelerated Care or Resources At Your Service & Accountability Our Values ICARE: Integrity, Compassion, Accountability, Respect, Excellence 32

Project Summary: Clostridium difficile Prevention Project Goals: Decrease and subsequently maintain the hospital Standardized Infection Ratio (SIR) <1.0. Reduce hospital onset C. difficile rates by 20% from 2015 rate of 11.3 to 9.1. Implementation of the C. difficile Tableau reporting for real-time tracking of unit and physician specific test ordering Develop comprehensive C. difficile prevention program Staff education/feedback regarding current state, goals and prevention program Team Members: Work Group Leader: Martin Griffel, MD Team Leader: Sadia Abbasi, MD Francina Singh, Healthcare Epidemiology Paul Murphy, Quality Improvement Eric Spitzer, MD, Laboratory Administration Gerald Kelly, MD, CMIO Cliff Roggemann, Environmental Services Martha Houlihan, Transport services supervisor Allison Copenhaver, ADN Medicine Laura Brooks, Nurse Manager Roderick Go, MD, Antibiotic Stewardship representative Melinda Monteforte, Pharmacy

Clostridium difficile spore Clostridium difficile ( C. d iff)

C. difficile infection is a result of two unique events Exposure to C. difficile Alteration of normal GI microbiota C. difficile infection (CDI) Healthcare facility Antibiotics Mild diarrhea Community Other Medications Fulminant colitis Sepsis Septic Shock Death

1. Ingestion of spores transmitted from other patients via the hands of healthcare personnel and environment 3. Altered lower intestine flora (due to antimicrobial use) allows proliferation of C. difficile in colon Background: Pathogenesis of CDI 4. Toxin A & B Production leads to colon damage +/- pseudomembrane 2. Germination into growing (vegetative) form Sunenshine et al. Cleve Clin J Med. 2006;73:187-97.

Why should you care about C. difficile? Prolonged hospital stays Increased readmissions Poor quality and financial outcomes Hospital onset C. difficile infections are reportable C. difficile falls under mandatory reporting events in NYS and is reported through the National Healthcare Safety Network (NHSN) This data is also used by other regulatory and rating agencies for benchmarking and pay for performance, including Center for Medicare & Medicaid Services (CMS), Vizient (UHC)

Categorizing CDI Stony Brook uses CDC Criteria: Lab ID Event Reporting for CDI identification. Lab ID event reporting requires positive test results be used without clinical evaluation of the patient. It is based strictly on the number of hospital days between the date of patient admission and the date of specimen collection. 3 days = Community-onset (CO) > 3 days = Hospital-onset (HO)

What are Stony Brook University Hospital s outcomes for HO C. difficile? Historically, SBUH had been high outliers in both NHSN and NYSDOH reports

What can we do to improve outcomes for C. difficile?

Adopting Best Practices Strict hand hygiene. Washing hands with soap and water is the most effective way to prevent transmission. Alcohol DOES NOT kill C.difficile spores Early and reliable diagnosis Contact precautions for patients with confirmed or suspected CDI until ruled out Effective daily and terminal cleaning of CDI patient rooms. Stony Brook will use Hydrogen peroxide based disinfectant effective May 2016, thought to be most effective sporicidial. Compliance with C. difficile powerplans

Process Change 2016 & 2017 Progress Current EPR guardrails and alerts reviewed for functionality and best practice solutions Enhanced alert mechanisms were put into place with further review throughout 2016 Resident lock-out for C. difficile testing when laxatives are documented as administered within 24 hours Attending alert per CDC guidelines to avoid C. difficile testing when laxatives are documented as administered within 24 hours Alert extended to 36 hours to laxative administration in May 2016 Expand both Resident lock-out and Attending alert to include <3 documented stools within the previous 24 hour period as of June 2016 Alert extended to 48 hours for laxative administration in October 2016 This alert is monitored on a monthly basis for accuracy of functionality and to analyze which units and providers are bypassing the alert. Between 10-15 bypasses per month Correlation of bypass and HO-CDI on a case by case basis Evidence of repeat lockouts by Residents

Process Change 2016 & 2017 Progress Developed an intensive education program which included both Learning Management System (LMS) review for all nursing staff, didactic training for all Nursing Educators, and in-person training for all medical services and resident groups. As of December 2016, over 3000 RN and CNA staff had been trained Expansion to all medical staff in 2017 Incorporated as part of annual recertification Antibiotic Stewardship enhanced to include the following processes for all high risk antibiotic orders Documented EPR indication on all orders 48 hour review by our Antibiotic Stewardship team Monday, Wednesday, Friday alerts to assess the need/route/dose Development of an IT Tableau C. difficile Dashboard Allows real-time tracking of Community Onset (CO) and Hospital onset (HO) C. difficile infections Current pilot testing with select team members

Process Change 2016 & 2017 Progress Clarification for Lab rejected specimens for unformed stool Review of current laboratory specimen rejection included Bristol Stool Chart types 1, 2, 3, and 4 Per CDC guidelines, recent efforts have ensured the lab will be rejecting type 5 & 6 samples as well testing only type 7 specimens Effective 11/17/16, the clinical laboratory will only accept specimens for Clostridium difficile PCR that are unformed/liquid stool [i.e., the specimen assumes the shape of the container (7 on the Bristol stool scale]. This change is based on the recommendation of the SBUH Preventing C. difficile Task Force and national guidelines ["test only patients with clinically significant diarrhea for C. difficile" (Infect Control Hosp. Epidemiol. 2014 Sep;35 Suppl 2:S48-65)]. Intensive RCA reviews on all HO cases, including unit feedback and EPR alert compliance monitoring Development of a new case review tool Continued review of all HO cases Patient room correlation reviews Unit-based feedback

Bristol Stool Scale Allows for an objective nursing assessment and documentation NIH

Process Change 2016 Progress Room Turnover/Housekeeping improvements Began ATP testing to monitor satisfactory cleanliness. High touch surfaces have achieved increased compliance throughout 2017 (>80%). BioQuell machine room turnover o Repaired in 2016 and strategies in development for inclusion in C.diff + terminal cleaning Bioluminescence (ATP) / Glo Germ Hand washing audits for Housekeeping staff Total n : 402 Pass: 59.70% Caution: 24.88 Fail: 15.42% 2016YTD High Touch Surfaces: YTD score 84.58% Manufacturers Guidelines 80% or better Above Target

Adopting Best practices Patients and visitors educational brochures are available on our Intranet under the Patient Safety First (PSF) site Also available from our print shop in both English & Spanish

Adopting Best Practices All proper isolation and room allocation procedures are outlined in our Infection Control Policy IC0022 When an order for a C. difficile PCR test is ordered by an authorized provider, the Electronic Medical Record (EMR) system automatically delivers an alert to the Nurses Task List indicating the need to initiate contact precautions. The RN initiates the isolation process as per SBUH Isolation Procedures. When a C. difficile test is reported as positive, initiated isolation precautions are continued. When a C. difficile test is reported as negative, the RN discontinues isolation.

Improvements and Achievements 49.5% decrease in Hospital Onset (HO) CDI volume achieved as of December 2017 with nearly 100 fewer HO CDI reported in comparison to 2015. 2016 SIR = 0.993, below our initial goal of <1.0. 2017 SIR = 0.766, below our stretch goal of <0.8 Laboratory CD testing volume has decreased by 42.6% with over 1300 fewer tests being performed in 2017 alone. This decrease is associated with more than $38,000 in laboratory testing reagent. Implementation of CDC C. difficile testing guidelines as validated IT guardrails Resident lock-out and Attending alert for C. difficile testing when laxatives are documented as administered within 48 hours Expanded alert to include both Resident lock-out and Attending alert for <3 documented stools within the previous 24 hour period Ongoing monitoring for alert bypass, compliance and patient safety

2.00 Stony Brook Medicine - Clostridium difficile Prevention NHSN C. difficile Incidence Rates Standardized Infection Ratio (SIR) 1.60 SIR = 1.281 SIR 1.20 0.80 0.40 Updated Q4 2017 data continues to hold our improvement with 7 consecutive quarters <1.0. SIR = 0.996 SIR = 0.766 0.00 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2013 2013 2013 2013 2014 2014 2014 2014 2015 2015 2015 2015 2016 2016 2016 2016 2017 2017 2017 2017 Cdiff HO SIR 2015 SIR = 1.281 2016 SIR = 0.996 2017 SIR = 0.766 Target = 1.0

Stony Brook Medicine - Clostridium difficile Prevention Hospital Onset (HO) C. difficile Incidence Rates per 10,000 Patient Days 25.00 HO Incidence per 10,000 patient days 20.00 15.00 10.00 5.00 0.00 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 HO Incidence Rate Annual HO Incidence Rate 95%CI

Stony Brook Medicine - Clostridium difficile Prevention Hospital Onset (HO) C. difficile - SBUH Volume 67 HO Total Volume 70 60 50 40 30 20 10 0 48 40 48 35 31 31 23 26 17 Q1 Q2 Q3 Q4 27 39 2017 2016 2015 2017 2016 2015

Stony Brook Medicine - Clostridium difficile Prevention Hospital Onset (HO) C. difficile - Unit Volume 18 16 14 12 HO Total Volume 10 8 6 4 2 0 19S 16N 15S 17S 09S MRN 12S 17N 18S 19N 15N 16S 18N 05CC 11S1 04L1 08BN 05SD 11S2 09N 11N 14S Axis Title 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017

1000 Stony Brook Medicine - Clostridium difficile Prevention C.diff Lab Specimen Testing - Quarterly Volume 900 800 867 834 700 738 675 651 663 Total Volume 600 500 400 300 200 100 579 20.7% decrease in laboratory CD testing in CY2016 in comparison to CY2015. (95% CI +/- 8.5, p=<0.0001) 729 fewer CD tests in 2016. 2017 continues to hold near 150 tests per month since lab testing guidelines were implemented in late November 2016. 499 436 432 473 446 0 Total Testing

A Few Don ts Don t test asymptomatic patients. Colonization is more common than infection. Suspect CDI in patients who have received antibiotics in the previous 8-12 weeks and have 3 or more diarrheal stools in 24-hours Do NOT order testing: o On formed stools. Lab will automatically reject the order o As a test of cure o For patients receiving laxatives for 48 hours. Such orders placed by house staff will be cancelled and will need to be reviewed by attending and ordered if considered appropriate o As a part of septic work up if not clinically relevant Remember we do lab ID event reporting Appropriate test ordering is very important

Winners of the Q4 2016 icare Award Data & Outcomes

An APIC Guide - Guide to the Elimination of Clostridium difficile in Healthcare Settings, Association for Professionals in Infection Control & Epidemiology. 2008 Infection Control and Hospital Epidemiology, Vol. 35, No. 6 (June 2014), pp. 628-645 Dubberke, E. et al. Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. The Society for Healthcare Epidemiology of America (SHEA), Volume 35.06, June 2014, pp 628 645 Antimicrobial Stewardship Toolkit, Greater New York Hospital Association, 2011 A Practical Guidance Document for the Laboratory Detection of Toxigenic Clostridium difficile, September 21, 2010, American Society for Microbiology References and Literature

Let s create a culture of accountability and make a difference! Any questions?

Questions and Hospital Discussion Facilitated by NYSPFP Staff David P. Calfee, MD, MS Teresa Lubowski, Pharm.D., B.S. Hospital Presenters 61

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