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KPNC Journey in the Fight Against C difficile Infection
Cristine Lacerna, RN, MPH, CIC Nancy Corbett, RN, MHA, CPHRM Paula Grant, RN,BSN, CIC
NCAL Risk And Patient Safety
Learning Objectives
Share the highs, the lows, and the pearls
KP Santa Clara Medical Center's experience
Discuss the various facets in the prevention of hospital associated C. difficile infection
CONFIDENTIAL. For internal use only.
The C. difficile Risk 14,000 deaths in the US each year. Infections are connected with receiving medical care. Almost half of infections occur in people younger than 65 more than 90% of deaths occur in people 65 and older. About 25% of C. difficile infections first show symptoms in hospital
patients; 75% first show in nursing home patients or in people recently cared
for in doctors' offices and clinics.
A National Health Threat
Deaths Caused by C. difficile Infections*
* Age-adjusted Rate of C. difficile as the Primary (Underlying) Cause of Death.
Source: CDC National Center for Health Statistics, 2012
Identification of the problem
I think I know why you have a headache, but I want to order some additional tests just to make sure…….
What do we know? – The hospital rooms occupied by symptomatic
patients were contaminated 49% of time – Rooms of asymptomatic patients were
contaminated 29% of time – C. difficile inoculated to floor stayed there 5
months – For patients with C. difficile + roommates, time to
acquisition was 3 days vs. 19 days – Of the hospital personnel caring for patients with
positive cultures, 59 percent had positive cultures for C. difficile from their hands
McFarland et al. NEJM. 1989; 320:204 210 --did daily c diff cultures on 428 hospital patients.
Room cleaning
Isolation
Hand Hygiene
Environmental Contamination Room contamination
– 49% rate if symptomatic C. difficile infection (CDI) v. 29% rate asymptomatic colonization
– Placement in a room w/a prior CDI occupant – More recent studies: Contamination rates vary between
2.5%-75% – Rooms occupied by non-infected/colonized patients may be
contaminated Environmental Survival
– Vegetative form 15 minutes - 6 hours – Spore up to 5 months
Reduce HA CDI
Reduce Transmission
Reduce Risk of Disease
Room & equipment Cleaning
Isolation
Reduce Unnecessary
ABX
Reduce Unnecessary
PPIs
Hand Hygiene
Affect All
HAIs
Driver of HA-PNA and CDI
What We Need to Do What needs to happen?
The Line was Drawn…
Northern California Kaiser C. difficile rates mirror that of the national trend since 2008
21 Medical Centers Variations across the
enterprise – THE challenge
CONFIDENTIAL. For internal use only.
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. difficile 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.
Ground Work
Dec 2010 Vital Behaviors for Hand Hygiene video created by Senior
Leaders
Jan 2011 Provided education to nursing leaders on hand hygiene vital
behaviors and the RIGHT bundle
April 2011 Began hand hygiene secret shopper audits Development of standardized workflows
April 2012 Deliberate Practice workshops
CONFIDENTIAL. For internal use only.
Standardize
How do we know we are cleaning the right
way?
How will we ensure all staff
have the right skill set and
knowledge?
How will we know we’re
cleaning effectively?
Developed Regional cleaning policies for the
core patient areas
Implement use of monitoring tools to audit
for effectiveness of cleaning
Train all EVS staff to 7-Step Cleaning
Procedure & Regional cleaning policies
CONFIDENTIAL. For internal use only.
Standardize
Antimicrobial Stewardship –Pharmacist & ID
physician Surveillance of targeted
antimicrobials Rounding with ID
physician
C difficile Prevention Bundle
R Risk Reduction
Isolation
Glove and Gown Etiquette
Hand Hygiene
Touch – Moveable Equipment Cleaning
I
G
H
T
Isolate at first sign infection
Contact Plus; Dedicated Equipment; PPE supplies; Isolate until discharge
Gel before, soap after gloves; Educate patient and family
Clean moveable equipment with bleach after each use
Gel in, soap out; Remind each other, Response: Thank you
HEROES GOES CSI
Controlling the Spread of Infection
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
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
Standardized Work Flows
Glove Etiquette Donning and removal of PPE Contact PLUS patient Transport Meal Tray Distribution Patient Ambulation Medication Administration Finger Stick Blood Glucose Cleaning Occupied Room Laboratory Blood Draw Radiology (at bedside)
No Shortcut to Becoming an Expert
Current Frame
Deliberate Practice
10,000 hour rule
Expert Performance
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.
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
Vital Behaviors for Hand Hygiene – Gel In-Wash-Out Notice and Speak Up
CONFIDENTIAL. For internal use only.
Rolling 12 Month HA-CDI Rate per 1000 Admits through April 2013
CONFIDENTIAL. For internal use only.
Reg HA-CDI Summit
(Apr 2010) Secret Shopper Audits
(Apr 2011) Deliberate Practice
Workshops (Apr 2012)
↓ 54% in 3 years
From 150 to 50 A C. difficile Journey
Paula Grant ,RN, BSN, CIC Kaiser Permanente Santa Clara Medical Center
California’s Silicon Valley hospital provides quality care for 300,000 members Facility features a medical office building and 327 bed acute care hospital More than 700 physicians and 4,300 staff
31 | © Kaiser Permanente 2010-2011. All Rights Reserved. June 12, 2014
In 2010 we started this journey
WE HAD A VISION
The 2010 C. difficile SUMMIT: Reduce transmission Reduce the burden
Provide clarity about what to do Provide a structured & safe environment to make
changes in care delivery
Determined to Be Different
1110 infections
Reduce C diff
infections by one third by July 1, 2011
Reduce C diff by half by July 1, 2012
C difficile Prevention Bundle
Risk Reduction
Isolation
Glove and Gown Etiquette
Hand Hygiene
Touch – Moveable Equipment Cleaning
R
I
G
H
T
Isolate at first sign of infection
Contact Plus; Dedicated Equipment; PPE supplies
Gown & glove in room, EVERYTIME!
Clean moveable equipment with bleach before removal from CDI room
“Foam in, Soap out”; Social Movement
Share the Vision
• Created definitions for Hospital and Community
associated C. difficile disease • Established benchmark for the year
• Monthly C. difficile dashboard with number of cases, rates, dedicated equipment isolation results shared
with leadership and frontline staff • Quality Performance Improvement nurses rounding
daily reviewing precautions
• Infection Preventionists providing data and updates weekly to leadership
• C.difficile algorithm as a guideline for isolation precautions
• Antibiotic stewardship rounds seven days a week by the pharmacist and ID
• Multidisciplinary drill down with-front line staff • The findings and learnings from all cases are given to
managers to present at the Healthcare Associated Infections Committee
Share the Vision
Smooth the Bumps in the Road
Bright yellow isolation PPE caddies on the patient room door for ease of use, removable floor “Stop” sign decals
EVS staff education, return demonstration competency validation and simulations
EVS performing ATP testing on “Contact Plus” discharge rooms Mobile equipment cleaning and disinfection with bleach Emergency Department partnership with initiating “Contact
Plus” precautions
CONTACT PLUS Precautions
CONTACT PLUS Signage • Floor “STOP” sign decal Yellow Caddy
– Filled with gowns, gloves
Isolation Caddy
Gowns
Gloves
• Hangs on patient room door •Contact •Contact Plus •Droplet
• Place Isolation Sign on patient door frame
• Ensure that PPE’s are sufficiently stocked with gloves, gowns and masks
• Wipe caddy down with SaniCloth AF3® after patient is discharged
• Leave isolation sign up so EVS is aware of room status
STOP sign floor decals are used for Contact Plus isolation rooms Clean floor decals after
removal from the floor with SaniCloth AF3
Isolation STOP Sign
ISOLATION
Workflow Improvements Send off 1st loose stool (either in ED or inpt unit) Educate PCTs:
– Collecting loose stools – Communication with the RNs regarding loose stool
Improved RN and physician communication – ICU discusses patient bowel habits in multidisciplinary rounds – Educated RN to place patient on precautions until physicians
are able to assess situation
IP sends a daily list of isolation patients to Quality PI RNs and EVS
2013 Lawrence Patient Safety Award
Awarded to four Northern California Kaiser Hospitals for its Reduction of Hospital Acquired Clostridium difficile Infection (HA-CDI) program Standardized practices reduced HA-CDI and also
reduced other hospital acquired infections and multi-drug resistant organisms
The Destination (we’re not there yet)
Key strategies
– Communication – Antibiotic Stewardship
– EVS cleaning and disinfection process
– Hand Hygiene Performance Improvement Program
– FLU vaccine to employees and members
Anchor a New Approach
We know what works and what doesn’t
What can we let go of safely and where can we add new methods?
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