Clostridium-Difficile Reduction Utilizing an Interdepartmental Team Approach Mary Jane Lamb RN, IP

1. Clostridium-Difficile Reduction Utilizing an Interdepartmental Team Approach Mary Jane Lamb RN, IP

2. Objectives • Demonstrate how APIE was used to facilitate solving our problem • Discuss how our team approach helped to improve care, reduce C-Diff #s and make staff happier • Discuss most recent changes to isolation and to lab testing

3. APIE • Assess • Plan • Initiate • Evaluate

4. Assess Problem Identify problem Increase in cases - 14 cases in 2007

5. Assess Problem Identify problem Increase in cases - 14 cases in 2007 18 CASES IN 2008 FROM JANUARY TO JUNE

6. Assess Problem Identify problem Increase in cases- 14 cases in 2007 18 cases in 2008 Jan – June Time Line • Indentify overlapping patients • Indentify primary departments involved Observe staff behavior • Not isolating until after diagnosis • Sharing commodes/toilets • Carrying dirty laundry out of room to hamper

7. Plan • Target Zero Task Force – Interdepartmental RNs, CNAs, Education staff, and Environmental staff 2. Review Policy and Procedure 3. Meetings with Patient Care Staff, Environmental Staff and Education

8. Implement 1. Revise Isolation Policies and C-Difficile Policy • All patients with diarrhea on isolation until cleared • Strict Contact Isolation • Double bag linen and trash 2. Mandatory education classes for all patient care staff 3. Revise Terminal Cleaning Policy • Expanded terminal cleaning • Wall to floor • Privacy curtains 4. Environmental Service education

9. Implement • 5. Add 2 Environmental FTEs for full 24/7 coverage

10. Evaluate 1. Staff reactions and concerns • Anger over number of isolation rooms • Concern over increase in isolation PPE • Concern/anger over extra time involved • Concern by Environmental staff that Patient Care staff was not using proper technique • Revise Isolation Policy again • Listened to concerns of Patient Care staff and Environmental staff

11. Evaluate • Decrease in C-Difficile numbers!!!!!

12. Immediate decrease in C-Difficile numbers 2007 – 14 cases/21796 X 10000 = Rate 6.0 2008 - 22 cases/21631 X 10000 = Rate 10.0 18 cases in 1st 6 months 4 cases in 2nd 6 months 2009 - 11 cases/20674 X 10000 = Rate 5.0 2010 - 8 cases/20255 X 10000 = Rate 4.0 2011 - 4 cases/14523 X 10000 = Rate 2.7 through Sept.

13. 2011 Changes • New Policy and Procedure Including definition of diarrhea • 3 loose stools in 24 hours Reemphasize when testing can be done • only 1 per day Decrease in Isolation time • stop isolation 24 hours after diarrhea stops Developed algorithm for C-Dif isolation

14. Patient has loose stool Initiate Contact Plus Isolation 3 or > loose stool In 24 hours No diarrhea or < 3 bouts in 24hs Obtain MD order for C-Diff test • Discontinue isolation • d/c stool testing with MD order C-Diff positive All cultures negative Continue isolation Note: If MD has ordered C-diff test and pt. has formed stool assess need for test with MD. Pt does not need isolation. Loose stools cease X 24 hrs Terminally Clean room D/C Isolation

15. NEW ISOLATION CATEGORY Contact Plus – used for C-Difficile and other organisms that are not effected by alcohol hand gel/foam • Gloves and gowns when entering room to touch anything in environment • Hand washing with soap and water

16. Toxigenic C- Difficile Testing NAAT – nucleic acid amplification method • This assay utilizes DNA amplification to detect the pathogenicity locus (Paloc) • Sensitivity and Specificity rates>95% • Neg predictive value of 99% • Pos predictive value of 92%

17. Testing Criteria Significant Diarrhea – 3 or more per 24 hours Submit Only 1 unformed stool • watery, loose, or taking the form of container Only 1 specimen will be accepted per diarrheal episode • Due to high sensitivity of negative test-no need to repeat • “Test for cure” for positive test not appropriate because patient may carry toxigenic C-Difficile for months after clinical cure Rare form stools may be accepted with approval of Lab Medical Director when requested by physician.

18. Thank You