c diff powerpoint session 3 140722 - · pdf filesession 3 –symptom ... vancomycin, for...

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IHI ExpeditionReducing Clostridium difficile Infections Session 3: Symptom Recognition, Precautions, and the Role of the Environment

July 23, 2014

These presenters have

nothing to disclose

Brian Koll, MDCarolyn Gould, MDDiane Jacobsen MPH, CPHQ

Expedition Coordinator2

Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action on Avoidable Rehospitalizations (STAAR) Initiative, the Summer Immersion Program, and IHI’s efforts for Medicare-Medicaid enrollees. Kayla leads IHI’s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the organization’s first employee health risk assessment, Kayla is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration.

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Expedition Director8

Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI) is currently directing the CDC/IHI Antibiotic Stewardship Initiative, NSLIJ/IHI Reducing Sepsis Mortality Collaborative. Ms. Jacobsen served as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) and directed Expeditions on Antibiotic Stewardship, Preventing CA-UTIs, Reducing C.difficle Infections, Sepsis, Stroke Care and Patient Flow. She served as faculty for IHI’s 100,000 Lives and 5 Million Lives Campaign and directed improvement collaboratives on Sepsis Mortality, Patient Flow, Surgical Complications, Reducing Hospital Mortality Rates (HSMR) and co-directed IHI’s Spread Initiative. She is an epidemiologist with experience in quality improvement, risk management, and infection control in specialty, academic, and community hospitals. A graduate of the University of Wisconsin, she earned her master’s degree in Public Health- Epidemiology.

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Today’s Agenda9

Introductions

Action Period Assignment

Debrief

Symptom Recognition,

Precautions, and the Role of the

Environment


Expedition Objectives

At the end of this Expedition, participants will be able to:

Explain the impact of the increasing incidence and

severity of C. difficile on hospitals

Discuss key approaches to preventing the spread of C.

difficile in the hospital setting

Identify and begin improving at least one key process for

impacting C. difficile in their hospital

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Schedule of Calls

Session 1 – Making the Case for Reducing Clostridium difficileInfections (CDI)

Date: Wednesday, June 25, 2:00 – 3:30 PM ET

Session 2 – Rapid Detection and IsolationDate: Wednesday, July 9, 2:00 – 3:00 PM ET

Session 3 – Symptom Recognition, Precautions, and the Role of the EnvironmentDate: Wednesday, July 23, 2:00 – 3:00 PM ET

Session 4 – Antibiotic StewardshipDate: Wednesday, August 6, 2:00 – 3:00 PM ET

Session 5 – The Role of LeadershipDate: Wednesday, August 20, 2:00 – 3:00 PM ET

Session 6 – Transitions and Long- term CareDate: Wednesday, September 3, 2:00 – 3:00 PM ET

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Action Period AssignmentRapid detection and precautions for C diff – test a process:

To expedite patients being placed on contact precautions when C diff is suspected or confirmed

- Test a flag, prompt, etc. to automatically initiate contact precaution when CDI test is ordered. (one unit, one nurse/unit clerk, refine based on initial test)

- Test a process to review patient placed on oral metronidazole or oral vancomycin, for need for contact precautions (one unit, one pharmacist/nurse, one day on MDR’s – refine based on initial test)

- Test a process to enhance STAT reporting of CDI, ie: critical value(one unit, one week, partner with laboratory – refine based on initial test)

What did you test/learn? Insights? Surprises?

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Faculty13

Brian Koll, MD, FACP, FIDSA, Executive Director for Infection Prevention, the Mount Sinai Health System, New York, NY, is a nationally-renowned and award-winning infection prevention expert. He has been featured on CBC Evening News for successful efforts to reduce central line associated bloodstream infections, on World News Tonight for successful efforts to control C. difficile, and in a national public service announcement regarding this disease by the Peggy Lillis Memorial Foundation.

Faculty14

Carolyn Gould, MD, MSCR, is a board-certified

Infectious Diseases physician and Medical

Epidemiologist in the Division of Healthcare Quality

Promotion at CDC. Dr. Gould joined the CDC and the

Commissioned Corps of the US Public Health Service

in December 2006. Her primary roles involve

responding to and preventing healthcare-associated

infections in acute care settings, with a special

expertise in C. difficile infections, catheter-associated

urinary tract infections (CAUTI), and antimicrobial

stewardship.

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A Tiered Approach to

Reduce Hospital Onset C.

difficile

Brian Koll, MD, FACP, FIDSA

Executive Director, Infection Prevention and Control, Mount Sinai Health System

Professor of Medicine, Icahn School of Medicine

Tiered Approach

1. Hand hygiene

2. Contact precautions

3. Sign placement

4. PPE readily available and used

5. Dedicated rectal thermometers

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Tiered Approach

6. Patient placement

7. Commodes

8. Environmentalcleaning protocols

9. Chlorhexidine bathing

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Tiered Approach

10. Antibiotic stewardship

11. Pharmaceutical stewardship

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Begins with Leadership

•Accountability

•Link infection prevention

with organizational strategy

and resources

•Link a culture of safety to

outcomes

•Engage and facilitate

teamwork

•Goal setting and

measuring and assessing

effectiveness19

Begins with Leadership

▶ All Formal Authority Positions

– Chairs, Chiefs, Managers,

Directors, Supervisors

▶ All Physicians

▶ Informal Leaders

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Begins with Those on the Front Line

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Begins with Diarrhea

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Isolation and Precautions

• Signage

• Availability of gowns, gloves, masks and N95

respirators

• Dedicated storage

• Monitoring of isolation rooms

• Cleaning of equipment between patients

• Hand hygiene

• Patient placement

• Private Room

• Cohorting23


Ownership

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MDRO Infection Prevention Bundles

2011 – 2013

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30

40

50

60

70

80

90

100

J2011 M M

J S N

J2012 M M

J S N

J2013 M M A O D

Co

mp

lia

nce

Ra

te %

Time

MSBI

MSBIB

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Environmental Contamination

• Environmental cultures:

• 100% of CDAD rooms with >1 positive culture.

• 33% of non-CDAD rooms with >1 positive culture.

• C. difficile has been recovered from up to 58% of

individual samples from patient rooms.

• Beds, stretchers, wheelchairs, sinks, toilets, walls, iv poles,

blood pressure cuffs.

• Outbreaks have been associated with reusable rectal thermometers.

Dubberke. Am J Infect Control 2007;35:315-8

Martirosian. J Clin Microbiol 2006;44:1202

Walker. J Hosp Infect 2006;epub April 6

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Environmental Disinfection

Eckstein et al. BMC Infectious Diseases 2007 7:61

Percentage of positive environmental cultures before and after housekeeping

cleaning and after research team disinfection with 10% bleach. (9 rooms)

Impact of Environmental Disinfection

Mayfield JL. Clin Infect Dis 2000;31:995-1000

Quaternary

ammonium

10% bleach Quaternary

ammonium

8.6* 8.1*3.3*

*cases per

1000 pt-days

http://www.biomedcentral.com/1471-2334/7/61/figure/F2?highres=y

http://www.biomedcentral.com/1471-2334/7/61/figure/F2?highres=y

http://www.journals.uchicago.edu/action/showFullPopup?doi=10.1086%2F318149&id=_e4

http://www.journals.uchicago.edu/action/showFullPopup?doi=10.1086%2F318149&id=_e4

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Monitoring of Environmental Cleaning

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Ownership

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Environmental Cleaning

Ownership by the Department

0

10

20

30

40

50

60

70

80

90

2011 2012H1 2012H2 2013Q1

Cleaning Compliance Rate EVS

IC

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A Picture Says One Thousand Words

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Handling of Linen

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Must be covered

No overflowing linen bins

Linen bins should be separated from clean equipment

Sani Cloths and Dispatch

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•Two minute kill time – CDI kill time is five minutes

•Tops must be covered

•Check expiration dates

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Ownership - Nursing

University of Nebraska

1. bathing three days per

week

followed by

2. daily bathing

followed by

3. four-month washout period

returning to standard

soap-and-water bathing

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Infect Control Hosp Epidemiol 2012;33:1094 - 1100


Ownership - Nursing

30% reduction in HO CDI with

three days per week protocol

59% reduction with daily bathing

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Infect Control Hosp Epidemiol 2012;33:1094 - 1100

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HO CDI

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Tiered Approach

1. Successful

2. Involvement at all

levels of the

organization

3. Sustainable results

4. Assure continued

improvement

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Questions?41

Raise your hand

Use the Chat

Carolyn Gould, MD, MSCR

Division of Healthcare Quality Promotion

Centers for Disease Control and Prevention

IHI CDI Expedition Session 3: Symptom Recognition, Precautions, Role of the Environment

Prevention of Clostridium difficile Infections

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

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CDC highlights preventing CDI

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm

Vital Signs: 6 Key Components of Prevention

Prescribe and use antibiotics carefully

Focus on an early and reliable diagnosis

Isolate patients immediately

Wear gloves and gowns for all contact with patient

and patient care environment

Assure adequate cleaning of the patient care

environment, augment with EPA-registered C.

difficile sporicidal disinfectant

Notify facilities upon patient transfer


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Vital Signs: 6 Key Components of Prevention

Prescribe and use antibiotics carefully

Focus on an early and reliable diagnosis

Isolate patients immediately

Wear gloves and gowns for all contact with patient

and patient care environment

Assure adequate cleaning of the patient care

environment, augment with EPA-registered C.

difficile sporicidal disinfectant

Notify facilities upon patient transfer


Early Detection and Isolation

Screen

patients for

new-onset

diarrhea on

admission and

on a regular

basis

Facilitate early

testing

Consider

nurse-driven

protocols

Pair testing with

order for Contact

Precautions

Use more

sensitive testing

methods

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Optimizing Testing

Enzyme immunoassay (EIA) for toxin sensitivity 48%-

67%

More sensitive tests:

Nucleic-acid amplification tests (NAAT)

• Polymerase chain reaction (PCR)

• Loop-mediated amplification (LAMP)

2- or 3- step testing algorithms using GDH + toxin testing of

positive specimens

• GDH less sensitive (79%-98%) compared to NAAT or toxigenic

culture in a recent meta-analysis

Tenover FC, Novak-Weekley S, Woods CW, et al. J Clin Microbiol 2010; 48:3719–24

Tenover et al. J Mol Diagn 2011;13:573-82

Peterson et al. Clin Infect Dis 2007;45:1152-60

Shetty et al. J Hosp Infect 2011;77:1-6

First and Foremost…

• For any testing method, you need a favorable pre-

test probability of disease for optimal performance

– Diagnostic accuracy improves with increasing

prevalence of disease in the population tested

• That means testing appropriately:

– Watery/unformed stool (conforms to shape of

container)

– At least 3 unformed stools in 24 hours

– Avoidance of repeat testing, tests of cure

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Potential Benefits of More Sensitive Testing

Fewer isolation days for negative patients

Fewer repetitive tests performed (46% at one institution

with restriction rules in place)

In theory, earlier treatment initiation, reduced

complications, and improved infection control

Gould et al. CID 2013;57:1304

Moehring et al. ICHE 2013;34:1055-61

Loo VG, Frenette C. Presented at ICAAC 2011. Abstract D-1273

Morgan M, Grein J, Ochner M, Hoang H, Jin A, Murthy R. Presented at ICAAC 2011

Belmares J, Pua H, Schreckenberger P, Parada J. [abstract 150]. Presented at SHEA 2011 Annual Scientific Meeting, 1–4 April, 2011; Dallas, TX

Goldenber g SA et al. ICHE 2011

Environmental Cleaning:

use of Sporicidal Agents

• EPA registered disinfectants with sporicidal claim:

http://www.epa.gov/oppad001/chemregindex.htm

• Limited data suggest disinfecting with bleach (1:10

dilution prepared fresh daily) reduces C. difficile

transmission in units with high endemic rates

• Therefore, sporicidal agents may be most effective

in reducing burden where CDI is highly endemic

Mayfield et al. Clin Infect Dis 2000;31:995-1000

Wilcox et al. J Hosp Infect 2003;54:109-14

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Current list of Agents with C. difficile EPA

Sporicidal Claim (list K) (N=25)

Product: ACTIVATE 5.25% INSTITUTIONAL BLEACH

Registrant: DEARDORFF FITZSIMMONS CORPORATION

Active Ingredient: Sodium hypochlorite 5.25%

Product: AUSTIN A-1 ULTRA DISINFECTING BLEACH

Registrant: JAMES AUSTIN COMPANY

Active Ingredient: Sodium hypochlorite 6%

Product: BUSTER

Registrant: CLOROX PROFESSIONAL PRODUCTS

COMPANY


Product: CLOROX ULTRA BLEACH 2


COMPANY

Active Ingredient: Sodium Hypochlorite 6.15%

Product: CONCENTRATED CLOROX GERMICIDAL

BLEACH1

Registrant: THE CLOROX COMPANY


Product: CPPC TSUNAMI


COMPANY

Active Ingredient: Sodium hypochlorite .55%

Product: DISPATCH HOSPITAL CLEANER

DISINFECTANT WITH BLEACH


COMPANY


Product: DISPATCH HOSPITAL CLEANER

DISNEFECTANT WITH TOWELS


COMPANY


Product: FF-ATH

Registrant: ECOLAB INC.

Active Ingredient: Ethaneperoxoic acid 5.8%,

Hydrogen Peroxide 27.5%

Product: GERONIMO 160A

Registrant: KIK INTERNATION INC.


Product: HASTE-SSD-COMPONENT A

Registrant: STERIS CORPORATION

Active Ingredient: Tetraacetylethylenediamine

61.6%

Product: HASTE-SSD-COMPONENT B

Registrant: STERIS CORPORATION

Active Ingredient: Hydrogen Peroxide 1%

Product: KIMTECH GERMICIDAL WIPE

Registrant: KIMBERLY-CLARK GLOBAL SALES,

LLC

Active Ingredient: Ethaneperoxoic acid .23%,

Hydrogen Peroxide 4.4%

Product: MASSASOIT A

Registrant: KIK INTERNATIONAL INC.


Product: METACOMET 160B



Product: OSCEOLA 160C



Product: PERIDOX RTU ™

Registrant: BIOMED PROTECT, LLC

Active Ingredient: Ethaneperoxoic acid .23%, Hydrogen Peroxide 4.4%

Product: PURE BRIGHT GERMICIDAL 160 BLEACH



Product: PURE BRIGHT GERMICIDAL ULTRA BLEACH



Product: RESTROOM CLEANER & DISINFECTANT



Product: SANI PROFESSIONAL BRAND NOROCLOTH GERMICIDAL DISPOSABLE

Registrant: PROFESSIONAL DISPOSABLES INTERNATIONAL, INC.


Product: STERIPLEX SD PART A

Registrant: SBIOMED, LLC

Active Ingredient: Silver .015%

Product: TECUMSEH B



Product: VIRASEPT


Active Ingredient: Ethaneperoxoic acid .05%,

Caprylic acid .099%, Hydrogen Peroxide 3.13%

Product: WAMPATUCK C



http://www.epa.gov/oppad001/list_k_clostridium.pdf Updated August, 2012

Assess Adequacy of Cleaning Before

Changing to New Cleaning Product

Carling et al. Clin Infect Dis 2006;42:385-8.

http://www.epa.gov/oppad001/list_k_clostridium.pdf

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http://www.cdc.gov/HAI/recoveryact/stateResources/stateResources.html

Environmental Cleaning Evaluation

Toolkit

Assessing Environmental Cleaning: ATP Method Compared to Fluorescent Marker

30 rooms of recently discharged patients, pre- vs. post

cleaning

Larger relative light unit (RLU) and fluorescent marker (FM)

reductions seen on

Bed control panel, phone, TV remote, bedside table

compared to:

Bathroom flush handle/grab bar, IV pole, bedrail, door handle

Greater RLU reductions associated with FM removal for the

first set of surfaces

Discrepancies on other surfaces

Differential adherence to cleaning vs. surface characteristics vs.

limitations of methods?

Murray et al. A comparison of ATP bioluminescence with surface fluorescent marker in assessing hospital room cleaning. Abstract: Am Society for Microbiology 114th General Meeting, May 14-17, 2014, Boston, MA.

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Mechanical Spore Removal: Though

Much Can be Achieved, Still More to Be

Done• Wiping alone (25 sq.cm.)

– Nonsporicidal disinfectant: 2.90 log reduction

– Sporicidal disinfectant: 3.70 log reduction

• Spraying alone

– Sporicidal disinfectant: 3.40 log reduction

– Prolonged drying times and no removal of debris

“We believe the use of a wiping procedure with a sporicidal agent provides excellent removal and inactivation of spores and is an integral part of C. difficile control measures.”

Rutala et al. Infect Control Hosp Epidemiol 2012;33(12):1255-1258

How Could Non-sporicidal Disinfectants

Fail in Practice?

• “Clean bench top surface” inoculated with 105 dried spores

• 10 second wipe with:

– Fresh hypochlorite wipe

– Used hypochlorite wipe (expended on 25 sq.ft. surface)

– Wipe saturated with quaternary ammonium agent

• Wipe (10 sec) of 4 successive “clean sites”

• 5 minute contact/drying

• Swab sampling of “sites”

– vortex in neutralizer,

– plated on agar

Cadnum JL et al. Infect Control Hosp

Epidemiol 2013;34(4):441-2

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Success in Reducing CDI Using a

Sporicidal Wipe for Daily and Terminal

Cleaning• Before/after study in two high-risk medical wards

• Intervention:

– Daily and terminal cleaning of ALL rooms with ATP monitoring

before/after (similar pass rate)

– Quaternary ammonium compound before

– Hypochlorite wipes with 10 minute contact time after

• Results: 24.2 to 3.6 cases per 10,000 patient-days (85% decline)

Orenstein et al. Infect Control Hosp Epidemiol 2011;32(11):1137-1139

Role of asymptomatic shedders in C. difficile transmission?

To what degree do asymptomatic carriers spread spores

to the environment?

How long do patients continue to shed after treatment?

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Asymptomatic carriers are a Potential Sourcefor Transmission of C. difficile among LTCF

Residents

Riggs et al. Clin Infect Dis 2007;45:992–8

Post Symptomatic CDI Carriage: Particularly Contagious Asymptomatic Carriers?

Sethi AK et al. Infect Control Hosp Epidemiol 2010; 31:21-27

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Only ~30% of Hospital-associated CDI Linked to Previous Symptomatic Cases

Using advanced, highly discriminatory typing

At least 29% definitively linked to asymptomatic

carriers

Transmission between wards common

Limitation: study did not use molecular diagnostics

Expect a greater proportion linked to prior symptomatic patients

(CDI) with increased sensitivity

Implications?

Should we test for asymptomatic carriage?

Special measures for asymptomatic carriers – e.g., gloves,

sporicidal disinfectants?

Curry et al. CID 2013, McDonald CID 2013

Contaminated Hands: Remember the Patients!

Donskey et al. Infect Control Hosp Epidemiol 2014;35:204

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Photo Title – Myriad Pro, Bold, Shadow,

20pt

Caption for photo, references, citations, or credits – Myriad Pro,

14pt

For more information please contact Centers for Disease Control and

Prevention1600 Clifton Road NE, Atlanta, GA 30333

Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-mail: [email protected] Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official

position of the Centers for Disease Control and Prevention.

Thank you!

Questions?

National Center for Emerging and Zoonotic Infectious Diseases

Place Descriptor Here

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Questions?65

Raise your hand

Use the Chat


Role of the environment:

Test a checklist to assess terminal Environmental cleaning: |* your current internal checklist and/or:“CDC Environmental Checklist for Monitoring Terminal Cleaning”

- Does your current process/procedure address all the components of the CDC checklist? (ie: are there additional that your organization has identified as necessary/important? Are there components you can add to enhance your current process?)

- Request input/feedback on current process from:1) Environmental Services: current barriers/constraints they encounter in completing terminal cleaning (ie: adequate time to turn around room? Reliable notification of patient w/C diff being moved/discharged? Other? )

2) Nursing: are there current constraints(ie: ensuring Env Services are promptly & reliably notified if C diff? High census? Lack of private rooms? Other?)

Incorporate input from Nursing and/or Environmental Services to test a change to your current process

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Expedition Communications

Listserv for session communications:

[email protected]

– To add colleagues, email us at [email protected]

– Pose questions, share resources, discuss barriers or successes

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Next Session

Session 4: Antibiotic Stewardship

Wednesday, August 6, 2:00 PM – 3:00 PM ET

Faculty: Belinda Ostrowsky MD & Phillip Chung PharmD

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mailto:[email protected]

mailto:[email protected]

c diff powerpoint session 3 140722 - · pdf filesession 3 –symptom ... vancomycin, for...

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