A REGIONAL APPROACH TO THE PREVENTION OF C. difficile INFECTIONS Ghinwa Dumyati, M.D. FSHEA Center for Community Health, University of Rochester Medical Center Elizabeth Dodds Ashley, PharmD MHS, FCCP, BCPS-ID Duke Antimicrobial Stewardship Outreach Network Teresa Murray Director, Provider Performance Improvement Excellus Blue Cross Blue Shield
Objectives 1. Highlight the value of collaboration for the prevention of healthcare associated infections 2. Describe the work of the Rochester Patient Safety Collaborative for the prevention of C. difficile infections (CDI) 3. Discuss the plan for expanding the C. difficile infection prevention model beyond the Rochester hospitals
Patient Sharing Between Healthcare Systems Facilitate the Dissemination of C. difficile Infections Nursing Home Outpatient Providers Hospital Nursing Home Hospital Nursing Home Nursing Home Outpatient Providers
Rochester/NY Emerging Infection Program data. Presented at IDWeek 2014 Dubberke ER, et al. Emerg Infect Dis 2008; 14:1031 8. Hunter JC, et al. Open Forum Infectious Diseases 2016;3(1):ofv196 Patient Sharing and Readmissions for C. difficile infections 32% of patients who develop CDI in nursing homes are transferred to the hospital Nursing Home 35% of Hospital onset CDI patients are discharged to a nursing home Hospital Home 57% of patients who develop CDI post recent hospitalization are readmitted 29% of community associated CDI are admitted to the hospital
Infection control is not under the exclusive control of a given hospital but is also influenced by the connections and number of connections that hospitals have with other hospitals. FIGURE 1 Map of hospitals (dots) and transfers (dark lines) in a force layout projection of the California data. Three major clusters in the California network, colored separately (San Diego in orange, Los Angeles in purple, and San Francisco and Northern California in green), were detected using network modularity clustering. This graph shows how tightly connected hospitals in California are.
The Rochester Patient Safety Collaborative for the Prevention of C. difficile infections
The Attributable Cost of Hospital Onset C. difficile Infections in the 4 Rochester Hospitals-2011 Cost LOS* Mortality ~ $6,408-9,124 per case ~ 3-12 days ~ 3-7% Total for 4 Rochester Hospitals ~$4-5 million Total for 4 Rochester Hospitals 1700-7,000 days Higher in elderly patients Does not include cost of re-hospitalization and recurrence of infection *LOS: length of stay Rochester Patient Safety Collaborative Scott RD: http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf Kwon JH et al. http://www.id.theclinics.com/article/s0891-5520(14)00080-4/pdf
Collaborative Structure A local project leader Oversees the data collection Create reports Helps to organize the project implementation Evaluate the direction of future interventions Steering Groups Sharing of experiences Sharing of tools across facilities Decisions made by the group
Rochester Patient Safety Collaborative Excellus Blue Cross Blue Shield Hospital CEO s Project Leadership & Coordination Antimicrobial Stewardship Team
The Collaborative Process Engagement Evaluation Education Execution Pronovost P, et al. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008;337:a1714
Rochester Patient Safety Collaborative Collaborative Timeline June 2010 Steering committee IP and Hospital Epidemiologists Quality and Safety Excellus June 2011 Monthly steering committee meetings initiated September 2011 Standardization of EVS and infection control policies and audit tools October 2011 Kickoff Meeting March 2013 Antimicrobial Stewardship Team Established 2011 2010 2012 2013 2014 March 2011 August 2011 September 2011 January 2012 January 2014 CEO s approval EVS steering Committee formed Hospital multidisciplinary teams established Infection Control and EVS audits 1 st antimicrobial stewardship intervention
Benefits of the Collaboration Comparative data drives competition and directs the various interventions CDI rates Compliance with audits Antibiotic days of therapy and treatment appropriateness The collaborative teams Standardize tools and policies Create position statements for antibiotic treatment and appropriate diagnostic testing The collaborative allows the implementation of interventions to be tailored to the local culture and needs
HIGHLIGHTS OF THE COLLABORATIVE WORK
PHASE I Infection Control and Environmental Cleaning
Standardization of Policies, Monitoring and Feedback I. Environmental Cleaning 1. Standardized policies for cleaning of the environment 2. Standardized audits of room cleaning done by EVS staff Face to face observations Tests for the presence of adenosine triphosphate (ATP) to verify cleaning effectiveness 3. Staff education http://www.rochesterpatientsafety.com/resources.html
Standardization of Policies, Monitoring and Feedback II. Infection Control Policies 1. Audits 2. Dedicated equipment grid: Who Cleans What 3. Decided as a group on policies for controversial infection control issues (e.g. how long to continue isolation of patients)
Equipment Cleaning Guidelines
http://www.rochesterpatientsafety.com/resources.html
Phase I Implementation at Each Hospital Local champions Essential to drive change Hospital multidisciplinary teams: Hospital leadership Infection Preventionist Hospitalist Hospital epidemiologist Quality and Safety Environmental service staff (EVS) Pharmacists Enhanced the collaboration between nursing, EVS and IPs Comprehensive Unit-based Safety Program (CUSP) or Positive Deviance Morning huddles CDI case assessments (mini root cause analysis) done Value analysis Admitting officer
Implementations Challenges and Solutions Terminal Room Cleaning Duration of cleaning: EVS collected data on the time needed to terminally clean rooms Data allowed the approval to hire additional staff Turnover of staff and efficiency: Dedicated staff assigned to terminal cleaning UV light disinfection Quality improvement methods used to improve communication between nursing, admitting office and EVS. Additional staff trained. Daily cleaning Cleaning around patient belongings: EVS staff were provided a script to interact with patients Expanded ATP testing to daily room cleaning audits Cleaning products: Bleach residue requires additional wiping of surfaces Trial of other sporicidal agents
Implementations Challenges and Solutions CDI cases review findings: Testing is inappropriate is up to 25% of patients: Educate staff on definition of diarrhea Guidelines for stool testing developed One hospital implemented an order entry which insured that stool were tested appropriately We needed to address antibiotic use!
PHASE II Antimicrobial Stewardship
High risk antibiotics: fluoroquinolones, β-lactams with β lactamase inhibitors, and extended-spectrum cephalosporins.
Step 1: Gather antibiotic use to benchmark across facilities Step 2: Identify trends in antibiotic use that either: 1. Differ between sites 2. Drive significant antibiotic use Step 3: Conduct targeted reviews of antibiotic use: Medication Use Evaluation(MUE) at each site (based on drug combination, clinical condition, agents of high use) Step 4: Review MUE data and craft intervention Step 5: Prepare position statement for dissemination at local sites Each stewardship team determined implementation and education strategy
Step 1: Total DOT/1000 PD by Hospital 900 Total Antibiotic DOT/1000 PD 850 800 750 700 650 600 550 500 1Q122Q123Q124Q121Q132Q133Q134Q131Q142Q143Q144Q14 A B C D* *Carbapenem data not included
Step 2. DOT/1,000 Patient Days by Agent 140 120 100 80 60 40 20 0
Step 3. What are antibiotics commonly used for in the hospital? Site* N = 981 (%) Lower respiratory infection 339 (34.5) Skin and soft tissue infection 185 (18.8) Urinary infection 141 (14.4) Gastrointestinal infection (includes CDI) 117 (11.9) Bloodstream infection 59 (6.0) Undetermined 42 (4.2) Intraabdominal infection 35 (3.6) Bone & joint infections 35 (3.6) Eyes/ears/nose/throat infection 25 (2.5) Hepatobiliary infection 25 (2.5) *Patients could be receiving antimicrobials for more than one clinician-defined therapeutic site Data from a CDC EIP point prevalence survey of antibiotic use in the Western NY region
Step 4. Quinolones Top 10 Indications
Step 3. Medication Use Evaluation for UTI http://www.cdc.gov/getsmart/healthcare/implementation.html
Step 4. UTI and Asymptomatic Bacteriuria Acute dysuria 2 urinary tract subcriteria 11 15 Microbiological criteria met in only 15 Did not meet symptom criteria 65 UTI: Loeb Treatment Criteria (n=91) 0 10 20 30 40 50 60 70
Step 4. Avoiding the Treatment for Asymptomatic Bacteriuria Collaborative position statement developed Guidelines for urine testing created by the hospitals Educational sessions targeted initially the internal medicine residents and hospitalists Identified the need to educate the emergency room physicians Appropriateness of UTI treatment in ED for the elderly patients was performed to guide the ED education
Step 5. Summary Statement For UTI
Step 5. UTI Testing Guidelines for ED
Step 5. Community Acquired Pneumonia
Step 5. The implementation of the CAP guidelines Approval by the various specialties and committees done by the hospital antimicrobial stewardship pharmacist and hospital epidemiologist The methods used for implementing the new guidelines differed: Change of the antibiotic order set for CAP Education, newsletter Review and feedback of patients treated for CAP Restriction of Moxifloxacin (occurred at a later stage)
Data Collection CDI Lab ID Event NHSN data collected by the IPs An NHSN group created to share de-identified data with project manager CDI testing appropriateness Assessed by the IPs EVS audits and ATP use Collected by EVS and shared with project manager Infection control data Isolation and dedicated equipment availability collected by IP and nursing Hand hygiene compliance routinely collected by each hospitals Pharmacy data Collected and summarized by pharmacists at the hospitals UTI treatment appropriateness assessment Collected by pharmacists using a CDC developed tool
So, what did we accomplish?
Results Change in Hospital Onset CDI 20 C. difficile Infection Rate (per 10,000 patient days) 18 16 14 12 10 8 6 4 2 0 Baseline Mean Confidence Interval Phase I. Implementation of EVS and Infection Control Interventions 36% decrease during 2015 as compared to baseline Phase II. Implementation of Antimicrobial Stewardship & continued follow-up Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2011 2012 2013 2014 2015 Quarter
Reducing Harm and Cost Saving 2015 Compared to 2011 Cost Saving LOS Reduction* 154 fewer cases ~ 3-12 days Total for 4 Hospitals ~$ 0.9-1.4 million Total for 4 Hospitals 462 1,848 days *LOS: length of stay Rochester Patient Safety Collaborative Scott RD: http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf Kwon JH et al http://www.id.theclinics.com/article/s0891-5520(14)00080-4/pdf
The Values of Participation in the Collaborative 1. Immediate Impact: Decreasing antibiotic expenditure 2. Project Goal: Improving patients outcomes by reducing the incidence of CDI and CDI related re-hospitalizations 3. Preparing for the Future: Antimicrobial Stewardship will be a CMS Condition of Participation within 3 years - March 2015: Specific Goal in National Action Plan for Combating Antibiotic-Resistant Bacteria - November 2015: Joint Commission draft standards released - December 2015: NQF Endorses National Healthcare Safety Network (NHSN) Antimicrobial Use Measure
Vision for The Expansion of The Collaborative The participating hospitals will form an inter-regional alliance that meets twice yearly However, the primary model will focus on a regional approach for the prevention of CDI as recommended by the Centers for Disease Control and Prevention Each region will: Identify A regional leader (physician or pharmacist) Form an advisory group: Consisting of hospital Quality and Safety, infection prevention, pharmacy, environmental staff and any other necessary staff Meet at least monthly to develop and implement regionallyfocused interventions with the assistance of the Rochester s advisors and coordinators
Vision for The Expansion of The Collaborative Due to the present differences in the antimicrobial stewardship programs 2 different options for participation are considered: Beginner: This program is for those hospitals without a current robust antimicrobial stewardship program and who may want mentorship by a hospital with an experienced program in their region/group Advanced: This program is for hospitals with existing antimicrobial stewardship program, and interested in enhancing their present program. They will specifically target antibiotics with high C. difficile risk (e.g. quinolones or syndromes where use of quinolone is common)
Interested hospitals will agree to sharing data and Information 1. Data: NHSN C. difficile LabID event Pharmacy data Preferably through emar Potential expansion of the agents collected for the HANYS project 2. Policies: Infection control and EVS policies and procedures regarding C. difficile 3. Additional data: Depends on the interest in the infection control or antimicrobial stewardship Decided upon by the collaborative group
Next Steps? 44 Decision? Additional 1:1 Conversations Commitment Finalize Expansion Group Regional Teams/Leads/Funding Model Contract Agreements Summer Kick Off!
Thank You