KPNC Journey in the fight against C difficile infection

1. KPNC Journey in the fight against C difficile infection

2. Learning Objectives Discuss the various facets in the prevention of hospital acquired C diff infection Share the highs, the lows, and the pearls KP Fresno Medical Center's experience CONFIDENTIAL. For internal use only.

3. The Problem • Nationally hospital stays associated with CDI has been increasing since 1993 (Source: AHRQ) • KP Northern California saw similar trend with a spike in 2008 • 21 Medical Centers and numerous associated Medical Office Building CONFIDENTIAL. For internal use only.

4. The line was drawn… • Aug 2009 • Expert panels to brainstorm on course of action • ID, IP, Leaders, PCS, EVS, Pharmacist • April 2010 • KPNC Regional C diff reduction summit • Kick off message by Regional President on target and expectation • Lay out the case for reduction • Introduction of RIGHT bundle & measures CONFIDENTIAL. For internal use only.

5. Ground work • Dec 2010 • Vital Behaviors for Hand Hygiene video created by Senior Leaders • Jan 2011 • Provided education to nursing leaders on HH vital behaviors and the RIGHT bundle • April 2011 • Began HH secret shopper audits • Development of standardized workflows • April 2012 • Deliberate Practice workshops CONFIDENTIAL. For internal use only.

6. Standardize CONFIDENTIAL. For internal use only.

7. Standardize How will we ensure all staff have the right skill set and knowledge? How will we know we’re cleaning effectively? How do we know we’re cleaning the right way? Developed Regional cleaning policies for the core patient areas Train all EVS staff to 7-Step Cleaning Procedure & Regional cleaning policies Implement use of monitoring tools to audit for effectiveness of cleaning CONFIDENTIAL. For internal use only.

8. Standardize Antimicrobial Stewardship Pharmacist & ID physician Surveillance of targeted antimicrobials Rounding with ID physician

9. The Challenge • How do we know a change is an improvement? CONFIDENTIAL. For internal use only.

10. The RIGHT Bundle • Risk Reduction Isolate at first sign of infection • Isolation Contact Plus, Dedicated equipment, isolate until discharge • Glove & Gown Etiquette Gel before and soap after gloves – educate patient and family • Hand Hygiene Gel in, soap out; Remind each other, Response: Thank you • Touch – Moveable Equipment Cleaning Clean moveable equipment with disinfectant between pts use and bleach before exiting Contact Plus CONFIDENTIAL. For internal use only.

11. Secret Shopper Audits • Regional Team audit 21 Medical Centers quarterly • Wide variation in practices within and across medical centers • Few had hardwired appropriate practices • Gloves applied without prior hand hygiene • High glove use in and out of rooms • Hand hygiene coming out of the room more reliable than going into the room • PPE was not always use or used properly • Work flows development began

12. Standardized Work Flows • After 5,000+ observations • Developed based on observed reliable practices • Tested and approved by content experts and pilot sites • Continue to learn with wide spread implementation • Recognized as best practice across organization

13. Standardized Work Flows

14. Deliberate Practice Practice Practice Practice CONFIDENTIAL. For internal use only.

15. No Shortcut to Becoming an Expert Current Frame Deliberate Practice Expert Performance 10,000 hour rule

16. 420 Representatives from 21 Medical Centers Nurses 163 Nursing Managers 25 EVS 46 Physicians 24 Infection Prevention 23 PCT/Transporter 19 Laboratory 17 Educators 16 Radiology 12 Non-Nursing Managers 11 Resp Therapy 11 Physical Therapy 9 Dietary 9 Quality/Risk Dept 8 Directors 7 ED 3 Pharmacy 1 Social Worker 1 Other 14 CONFIDENTIAL. For internal use only.

17. Deliberate Practice Stations • Speaking Up with Greg and Robbie – Vital behaviors for hand hygiene • Holey Glow – Hand Hygiene and Glove Etiquette • We Got You Covered – Proper application and removal of PPE • What the Bleach? – Cleaning moveable equipment • Out and About – Transport of C diff patient • Not Just a Maid Service – EVS cleaning • The Wow of the Wows – Medication administration and cleaning of moveable computer and scanner • All Stuck Up – Lab draws

18. Nancy, please choose and insert work flows, videos, etc. CONFIDENTIAL. For internal use only.

19. Rolling 12 Month HA-CDI Rate per 1000 Admits through April 2013 Reg HA-CDI Summit (Apr 2010) Secret Shopper Audits (Apr 2011) Deliberate Practice Workshops (Apr 2012) ↓ 54% in 3 years CONFIDENTIAL. For internal use only.

20. Fresno Team insert slides CONFIDENTIAL. For internal use only.

21. Clostridium Difficile Kaiser Foundation Hospital, Fresno Infection Prevention & Control Risk Priority

22. C Difficile Prevention Risk Reduction Hand Hygiene Cleaning (Environment & Equipment) Antibiotic Stewardship Education

23. Risk Reduction • Clostridium Difficile was identified as the top priority for the Fresno Medical Center in November 2009 by the Infection Control Committee. Recognized as a priority every year since. • A multidisciplinary work group was initiated to begin the work and risk mitigation efforts. • The work group efforts was aligned with the regional HEROES (CSI) Group. • Increase in the work groups multidisciplinary scope to include a wider range of departments.

24. Risk Reduction • Collect specimen with the first diarrhea episode – Initiate CONTACT PLUS precautions – Call physician for lab order. • Place ‘hat’ in toilet for all new admissions • Alert other departments when patient has procedures done outside of room (i.e. Radiology) • Dedicated equipment only: (disposable B/P cuff, Stethoscope, Thermometer, O2 sat probe) WANDA & other equipment the patient may require • Provide commodes for ER patients with diarrhea and ease of specimen collection

25. Dedicated Equipment

26. Hand Hygiene • The Hands Give It Away

27. Complete medical center Degermerassessment was under taken in 2010, reassessment in 2012. • Hand Hygiene Hero • Secret Shoppers • Frontline staff engagement and empowerment • Three vital behaviors • CHAMPS

28. OFFICES ED ASSESSMENT 14 QUIK-CARE ALREADY IN PLACE 9 ADDITIONAL TO BE PLACED

30. 12 QUIK-CARE ALREADY IN PLACE 8 ADDITIONAL TO BE PLACED 3 EAST ASSESSMENT

31. 11 ADDITIONAL TO BE PLACED 13 QUIK-CARE ALREADY IN PLACE 3 WEST ASSESSMENT

32. 14 QUIK-CARE ALREADY IN PLACE ADDITIONAL TO BE PLACED 7 4 EAST ASSESSMENT

33. 14 QUIK-CARE ALREADY IN PLACE 8 ADDITIONAL TO BE PLACED 4 WEST ASSESSMENT

34. 2010 Alcohol Degermer Final Assessment 83 QUIK-CARE CURRENTLY IN PLACE Hand Hygiene Task Force 47 ADDITIONAL PROPOSED PLACEMENT 50 ACTUAL PLACED • CCU Department • No Additional Alcohol Degermer Mounting Required • “Free Standing” Quik-Care Foam Canisters Placed in Every Room

35. 2012 Alcohol Degermer Final Assessment 143 QUIK-CARE CURRENTLY IN PLACE 22 ADDITIONAL PROPOSED PLACEMENT 22 ACTUAL PLACED • Labor and Delivery / Postpartum • “Free Standing” Quik-Care Foam Canisters Placed in Every Room

36. Gel in / Gel Out Notice & Speak Up Say Thank You Three Vital Behaviors • Gel in before you enter a patients room • Gel out when leaving a patients room • Use soap and water for Contact Plus patients • You see a co-worker forget to wash their hands • Remind them to wash their hands • Say thank you and wash up if someone reminds you to wash your hands

37. Wash hands for 20 seconds before preparing trays Contact or Contact Plus Isolation room Patient not in Isolation Requires a disposable tray Cart used, tape small trash bag on side of cart PASSING MEAL TRAYS Cart used, tape small trash bag on side of cart Gel/foam hands , put on PPE as required including gown and gloves • Gel/foam hands • Pickup tray ticket and take into patients room • Check 2 patient identifiers • Correct patient – then pick up tray from cart and take into patients room. • Remove PHI from tray ticket and place in trash bag taped to cart • Pick up tray ticket and enter patients room • Check 2 patient identifiers • Return to Cart without leaving patients room • Pick up tray and take tray into patients room • Remove PHI from tray ticket and place in trash bag taped to cart Gel/foam hands when leaving room and before entering next patients room Remove PPE before leaving patients room, place in trash in room • Upon exiting the patients room for Contact Plus Isolation, immediately wash hands with soap and water for 20 seconds • For Contact Isolation, gel/foam hands on exit If the cart is pushed or cart handles touched, gel/foam hands again before taking tray into the room. Gel/foam hands on exit from room Repeat for each patient Repeat for each patient At end of Meal Service dispose of PHI bag in secured PHI container 10/2013

38. ASSISTING OUT OF THE ROOM AMBULATION FOR A PATIENT ON CONTACT OR CONTACT PLUS ISOLATION If patient is unsteady on their feet, collaborate with a second patient care staff member to provide assistance to the patient at the door. When ready to leave room, remove gown and gloves and wash hands. • Verify that the following steps have been completed with the patient’s nurse. • Prior to ambulating out of the room, the patient must: • Have diarrhea contained or be continent of stool (i.e. diaper, rectal tube, rectal bag, etc.) • Have a bath or shower • Have a complete linen change • Have drains/drainage bags emptied • Have drains secured to gown • Put on a clean gown • Wash their hands with soap and water for 15 seconds • Ambulation should be limited to patient’s unit. • Exceptions should be approved through Infection Prevention and Control • The patient is not allowed to visit other patients, ambulate into kitchen/pantry on the unit, into the cafeteria, gift shop, or waiting rooms PPE is used per Standard Precautions (contact with blood, body fluids, non-intact skin) Return patient to room 2staff members may be needed: one to assist the patient in the room before and after ambulation and the second to provide assistance while ambulating. If patient is unsteady on their feet, collaborate with a second patient care staff member to provide assistance to the patient at the door. Perform hand hygiene (gel in) and put on gown and gloves Perform hand hygiene (gel in) and put on gown and gloves Assist patient to bed or chair If an assistive device is needed, clean with bleach wipe before and after use. (Must be allowed to dry before touching.) When ready to leave room, remove gown and gloves and wash hands 10/2013

39. ASSISTING OUT OF THE ROOM AMBULATION FOR A PATIENT ON CONTACT OR CONTACT PLUS ISOLATION If patient is unsteady on their feet, collaborate with a second patient care staff member to provide assistance to the patient at the door. When ready to leave room, remove gown and gloves and wash hands. • Verify that the following steps have been completed with the patient’s nurse. • Prior to ambulating out of the room, the patient must: • Have diarrhea contained or be continent of stool (i.e. diaper, rectal tube, rectal bag, etc.) • Have a bath or shower • Have a complete linen change • Have drains/drainage bags emptied • Have drains secured to gown • Put on a clean gown • Wash their hands with soap and water for 15 seconds • Ambulation should be limited to patient’s unit. • Exceptions should be approved through Infection Prevention and Control • The patient is not allowed to visit other patients, ambulate into kitchen/pantry on the unit, into the cafeteria, gift shop, or waiting rooms PPE is used per Standard Precautions (contact with blood, body fluids, non-intact skin) Return patient to room 2staff members may be needed: one to assist the patient in the room before and after ambulation and the second to provide assistance while ambulating. If patient is unsteady on their feet, collaborate with a second patient care staff member to provide assistance to the patient at the door. Perform hand hygiene (gel in) and put on gown and gloves Perform hand hygiene (gel in) and put on gown and gloves Assist patient to bed or chair If an assistive device is needed, clean with bleach wipe before and after use. (Must be allowed to dry before touching.) When ready to leave room, remove gown and gloves and wash hands 10/2013

40. Hand Hygiene • Hand Hygiene Hero • Secret Shoppers • Frontline staff engagement and empowerment CONFIDENTIAL. For internal use only.

41. CHAMPS (Clean Hands Are Making Patients Safer) • Positive reinforcement by calling out when you observe someone washing their hands • Observe each other • Post results in all patient unit areas for staff to track their progress CONFIDENTIAL. For internal use only.

42. Cleaning (Environment & Equipment ) • The Environmental Service Department implemented extensive training in effective room cleaning with the use of Sodium Hypochlorite. • The cleaning is validated by the use of Adenosine Triphosphate (ATP) meter which measures the relative light units (RLUs) of the 14 High Frequently Touched Surfaces. • The system indicates overall biological contamination including microbiological and product residues. This approach has been instrumental in reducing the microbial load on the highly touched surfaces around the patient’s room.

43. Bleach only for cleaning throughout the facility • ATP random testing on clean rooms • Pilot for disposable curtains with embedded antimicrobials - now used in most patient care areas • Alert EVS when patient is transferred between rooms or discharged and CONTACT PLUS precautions in place.

44. Touch It, Clean It: Moveable Equipment

45. Antibiotic Stewardship • Jan-Sep, 2010: • 301 patients followed; 33 with positive C. difficile culture • 200 Pharmacist recommendations made with 93% acceptance rate by physicians. • 2012: • ID physician provided intense education to a select group of pharmacists and continues to meet with them monthly and as needed

46. Education • Intense Drill Down of every Hospital Associated Clostridium Difficile Infection What happened? Why it happened? Could we have prevented it? What can we do to make sure it doesn’t happen in the future?

47. Education • Annual Skills • Advocates on all units around the clock serve as a resource to our front line staff in their daily work flow. • Specimen collection items placed in every new admission’s bathroom • Daily briefing to review every isolation patient and every specimen needed for collection • Stool Characteristics Report • Escalation process for specimen collection

48. Stool Characteristics Report CONFIDENTIAL. For internal use only.

49. C. difficile is More Prevalent in the Community than in the Hospital

50. Community – Acquired Clostridium difficile Infection is More Common Than Hospital-Onset in Hospitalized Patients A Two-Year Retrospective Study Background: Hospital-Onset Clostridium difficile Infections (HO-CDI) are a major focus for infection prevention in the United States. Little data exists on the relationship between Community Onset Clostridium difficile Infections (COCDI) and HO-CDI. Preventing Clostridium difficile infection (CDI) in the Community has been overlooked. This study will outline the importance of CO-CDI rates and its impact on the HO-CDI rates. Harold Lin, MD; Raed Khoury, MA, MPH; Thomas Lam, MD; Kurt Hishida, RN; Krickett Pal, RN; Elisa Porter, BA; Dee Lacy, MD – Infectious Diseases and Infection Prevention Team Methods: This was a retrospective study of all 158 CDI patients admitted to Kaiser Permanente Hospital, Fresno, California in 2011 and 2012. CO- CDI was diagnosed when a patient had unexplained diarrhea and a positive stool test for CDI within 72 hours after admission. Patients that were admitted whose stool tested positive but were in the hospital within the previous 4 weeks were defined as Community-onset healthcare-associated CDI (COHA- CDI). In the Initial 4 months of the study (18% of the cases [29 of 158]), we utilized Enzyme Immunoassay (EIA) to detect toxins for diagnosis. For the remaining cases (82% of the cases [129 of 158]), we used EIA to detect Glutamate Dehydrogenase and confirmed toxins by Polymerase Chain Reaction. We also reviewed antibiotics, proton pump inhibitors (PPIs) and H2 Blockers prescribed within 30 prior to CDI for all 158 cases. Results: Out of all patients admitted to the hospital with CDI: 60% (n=95 of 158) were identified as CO-CDI; 23% were HO-CDI; 17% CO-HA-CDI. During the beginning of this study period, 9% (n=14 of 158) of the CDI could have been identified as CO-CDI had the testing been timely. The incidence of CO-CDI increased 14% from 2011 (n=45 of 158) to 2012 (n=50 of 158). Among CO-CDI cases, 73% received antibiotics, 32% H2 Blockers, and 25% PPIs within 30 days prior to CDI. For HO-CDI cases, 94% received antibiotics, 58% H2 Blockers, and 44% PPIs. Conclusion: Incidence of CO-CDI in hospital is more significant than generally appreciated. Importance of CO-CDI should not be overlooked in the effort to reduce HO-CDI infections. H2 blockers are more significantly involved in all CO-CDI, HO-CDI and CO-HA-CDI cases compared to PPIs. More research is needed to truly identify the impact of CO-CDI on Hospital Rates and the role of H2 blockers in CDI.