Clostridium difficile Bundle

1. Clostridium difficile Bundle Hospital Epidemiology and Infection Control Development Implementation Compliance Outcomes Amy Nichols, RN, MBA, CIC Director February 2014

2. Objectives • By the end of this session, you will be able to describe: • Rationale for CDI Bundle • Bundle element development • How one organization implemented the Bundle • Bundle data collection challenges and successes • By the end of this session, you will be able to: • Develop an institution-specific implementation packet • Create institution-specific reports

3. Overview • CDAD/CDI appears to be increasing and may be more virulent • Careful diagnosis is necessary • Apply appropriate clinical criteria for testing • Do not perform multiple tests within 1 week • Use the most sensitive test first (rtPCR) • Do not perform test of cure assay • Enhanced physician education is needed

5. 2012 CDPH Reports http://www.cdph.ca.gov/programs/hai/Pages/CDI-Report.aspx

6. Aggregate CDI Rate by Adult and Pediatric Hospitals

7. Hospital Onset CDI, VRE, and MRSA

8. Lab Test for CDI • 2014: NHSN requires reporting type of test used at your facility for CDI reporting • PCR=90% sensitive, 96% specific • EIA significantly lower for detection FV Tenover, JCM 48:3719, 2010

9. SHEA/IDSA Compendium Perform testing on unformed stool Do not test asymptomatic patients or for “test of cure” Stool culture is most sensitive test Toxigenic culture is the gold standard for CDI testing EIA is suboptimal for diagnostic testing GDH followed by cell cytotoxicity or toxigenic culture is a potential option for testing (2-step procedure) rtPCR may be the optimal test-more data needed Repeat testing is of limited value SH Cohen et al, ICHE 31:431-55, 2010

10. CDC Guidance (8/16/2010) Suspect CDI in patients who have received antibiotics in the previous 8-12 weeks and have 3 or more diarrheal stools in 24 hours The current testing gold standard is a toxigenic culture, but turnaround time is slow Rapid tests that approach the sensitivity and specificity of toxigenic culture include PCR tests or 2-step testing paradigms that use rapid antigen assays with confirmation C. Gould, http://www.medscape.com/viewarticle/725822

12. Bundle Element Development 1. Gould, C., MD; MacDonald, C., MD. Clostridium difficile (CDI) Infections Toolkit. ELC Prevention Collaborative. Division Healthcare Quality Promotion, Centers for Disease Control and Prevention. December 2009. 2. National Healthcare Safety Network, Multidrug-Resistant Organism (MDRO) and Clostridium difficile – Associated Disease (CDAD) Module. http://www.cdc.gov/ncidod/dhqp/nhsn.html. 3. Ghantoji SS, Sail K, Lairson DR, Dupont HL, Garey KW., Economic healthcare costs of Clostridium difficile infection: a systematic review. Journal of Hospital Infections. 2010 Apr; 74(4):309-318. Clostridium difficile Infection (CDI) increased in U.S. hospitals over last three decades (1). CDI causes greater length of stay, increased cost, and higher mortality (2, 3). National average = 4 - 10 cases/10,000 pt days; UCSF Medical Center’s HO-CDI rate for calendar year 2011 = 10.2 cases per 10,000 patient days.

13. Methods 4. Cohen SH, MD; Gerding DN, MD; Johnson S, MD; Kelly CP, MD; Loo VG, MD; McDonald LC, MD; Pepin J, MD; Wilcox MH, MD. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control Hospital Epidemiology 2010; 31(5):431-455. • Literature review provided guidance for creating an evidenced-based practice checklist and a CDI Surveillance workplan. • An Interdisciplinary Practice Bundle was created based on recommendations with the most rigorous evidence. • Two additional practices for decreasing CDI transmission were added in response to ­­­­­­­­­evidence that decreasing the bioburden on both the patient and in the environment decreases transmission (4). • Seven patient care units selected based upon high CDI rates.

14. CDI Bundle Audit Tool

17. Methods • ICP solicited input from clinical leaders regarding CDI on their units and evaluation of proposed IPB. • Bed Management engaged to carry out IPB patient flow requirements. • IPB implemented March 2012 • Created CDI tracking system for increasing CDI awareness and reducing transmission. • Findings shared with clinical leaders via electronic and in-person communications. • Unit-based feedback provided • Just-in-time coaching provided to participating units

18. Observations • UCSF Medical Center utilized all top-recommended practices for tracking and decreasing CDI cases. • Main focus shifted to: • Moving an asymptomatic patient to a clean room • Ensuring daily bathing for patients with active CDI.  • Other focus areas: • Track onset of symptoms • Reducing time from symptom onset to isolation • Reducing time from symptom onset to obtaining specimen

19. Observations • Iterative education: • After the units understood the rationale for applying Contact Isolation Precautions for symptomatic patients and for moving asymptomatic patients to clean rooms, the compliance in both areas increased. • Challenges: • Temp staff hired for EHR implementation • Lack of proper charting for timing of isolation, stool count and stool type, and patient hygiene.  

20. CDI Prevention Bundle Staff Education • Initiate & document contact isolation precautions for patients with diarrhea (3 or more unformed stools in 24 hrs): • Nurse initiates contact precautions. • Clean hands. • Don gown and gloves when entering patient room. • Move patient to private room with a dedicated toileting facility. • Use Diarrhea Decision Tree to guide practice. • Send loose stool sample to lab to test for CDI: • MD order required.

21. CDI Prevention Bundle Staff Education • Hand hygiene: • Always wash hands with soap and water on EXIT after removing gloves (Gel In/ Wash Out). • OK to use gel on entrance prior to gloving. •  Educate patient & family about CDI: • Educate patient and family about Clostridium difficile http://patiented.ucsfmedicalcenter.org/docs/Additional_Patient_Ed_Resources/About%20Clostridium%20Difficile.pdf • Educate about precautions stressing hand hygiene by washing with soap and water on EXIT.

24. CDI Prevention Bundle Staff Education • Decrease bioburden of C. diff spores on patient: • Daily bath or shower for patients with known or suspected CDI. • Cleaning: • Use dedicated patient-use items for isolated patients. • Clean patient-use items with Sani-Cloth. • Hospitality will use bleach-based cleaner for daily room cleaning and all Discharge Room cleaning.

25. CDI Prevention Bundle Staff Education • Move patient with CDI to new room once symptoms resolve: • Educate patient & family about testing expectations. • Educate patient & family about need to move out of contaminated environment to clean one.* • Bathe or shower patient before moving to clean room. • Unit staff will request a room transfer within 24hrs: • Write comments in comment section stating: “C.diff precautions removed. Transfer to new room.” • The nurse or MD will discontinue isolation precautions. • Leave isolation caddy on door until Hospitality has completed Discharge cleaning. • If patient cannot be transferred to a new room, patient continues on contact precautions in existing room until room change or discharge and existing room is cleaned with bleach-based cleaner.

26. CDI Prevention Bundle Staff Education • *Suggested Script: “Now that you no longer have an active infection, moving you to a clean room and making sure you are freshly bathed / showered will decrease the chance of healthcare workers spreading the C.diff from this contaminated room to other areas of the hospital or other patients.” • Practice antimicrobial stewardship: • Use Clinical Pharmacy’s Guidelines for Antimicrobial Use in Adults with CDI

28. Recommendations • Interdisciplinary approach must engage Nursing, Microbiology, EVS, Providers • Utilize multiple communications strategies to: • Identify symptomatic patients • Timing for contact isolation and stool sample submission • HCW reminders for hand hygiene • Push unit-specific and institutional CDI and DAZO data routinely to interdisciplinary teams

31. Conclusions Conclusion: CDIs will continue to increase because the population over 65 years of age has the highest risk of contracting CDI and this is the fastest growing demographic. Implementing this Interdisciplinary Practice Bundle is a preliminary step for UCSF Medical Center in reducing CDI rates and providing better outcomes for patients.