HEN 2.0 C.DIFF WEBINAR SENDING STOOLS, MANAGING ANTIBIOTICS, AND OTHER PRACTICAL INFORMATION. June 30, :00 a.m. 12:00 p.m.

Transcription

1 HEN 2.0 C.DIFF WEBINAR SENDING STOOLS, MANAGING ANTIBIOTICS, AND OTHER PRACTICAL INFORMATION June 30, :00 a.m. 12:00 p.m. CT 1

2 WELCOME AND INTRODUCTIONS Mallory Bender, Program Manager HRET 11:00 11:05 2

3 AGENDA FOR TODAY 3

4 C.DIFF CHANGE PACKAGE Cha C.diff driver diagrams and change ideas Example PDSA cycles Descriptions and guidance on how to use change package effectively Referenced appendices 4

5 ENCYCLOPEDIA OF MEASURES (EOM) Catalogued measure information available on the HRET HEN website HEN Core Topics (evaluation measures) HEN Core Process Measures HEN Additional Topics 5

6 SIGN UP TODAY: INFECTIONS LISTSERV Infections Analytics Listserv is available for: Sharing of: HRET Resources Publically Available Resources Best Practices Learnings from Subject Matter Experts Troubleshooting for Data Reporting and Analysis Sign Up Here 6

7 HEN DATA UPDATE Richard Rodriguez, Data Analyst HRET 11:05 11:10 AM 7

8 C. DIFFICILE : HEN 2.0 EVALUATION MEASURES 8

9 C. DIFFICILE : HEN 2.0 EVALUATION MEASURES 9

10 HEN 2.0 C. DIFFICILE RATE Data submitted to AHA/HRET as of: 5/27/

11 IF IT AIN T LOOSE, IT S OF NO USE Stephen Brecher, PhD, VA Boston Health Care System/Boston University School of Medicine 11:10 11:25 AM 11

12 The opinions expressed in this presentation are those of the presenter and do not necessarily represent the views of the Veterans Affairs HealthCare System I have no financial disclosures relevant to this presentation

13 ACUTE INFECTIOUS DIARRHEA million cases/year in USA Why does my patient have diarrhea? Infectious causes vs non-infectious causes Gastroenteritis usually associated with nausea and vomiting Clinically Significant Diarrhea >3 loose unformed stools/24 hours or >250 g of unformed stool/day 1. DuPont, HL. N Engl J Med :

14 BURDEN OF CDI IN THE US surveillance study of 10 geographical areas in US used to predict annual number of cases, types and outcomes 453,000 cases, 83,000 first recurrences 29,300 deaths 65.8% HCA (24.2% while in a hospital) 34.2% CA Risk : female, white, > 65 years old 1. Lessa et. al. N Eng J Med :

15 Who Should I Test? 15

16 CHANGING DIFFICILIOLOGY It used to be easy Hospitalized patients on antibiotics with diarrhea Bad tests but we didn t know better and repeated them until they were positive (CD x 3 or more) No longer easy because Community, health care associated and nosocomial CDI Risk factors beyond antibiotics Many reasons for diarrhea, particularly, in hospitalized patients 16

17 GOALS OF TESTING Identify cases of CDI and rule out CDI in patients with diarrhea 1 Initiate specific treatment plans for patients with CDI Maximize infection control interventions and environmental cleaning in rooms of CDI patients and carriers to prevent transmission 1. Polage, CR et al. Nosocomial Diarrhea: Evaluation and treatment of causes other than C. difficile. Clin Infect Dis :

18 WHO TO TEST Persons with 3 unformed BM within 24 hours with risk factors for CDI (Clinically Significant Diarrhea) WBC, creatinine, albumin, antibiotics, IBD, surgery, and older age (older than me) Patients who completed therapy who still have CSD Do not perform tests on everyone with diarrhea Laxatives, tube-feeding, diabetes, etc. Do not perform tests on asymptomatic patients Do not get coerced by Test of Cure requests Cured patients can carry toxigenic C. difficile How many of you have been told by a LTC facility We need 3 negative Cdiffs before we can take your patient? 18

19 WHAT TO TEST THE BRECHER GUIDELINES 1 Only test loose or liquid stool If it ain t loose, it s of no use Stick test for stool consistency If the stick stands, the test is banned If the stick falls, test them all Bristol Chart 5-7? 1. Brecher, SM et al CID.57:

20 What Clinical Symptoms Help Determine if the Patient has CDI? 20

21 C. DIFFICILE CLINICAL PICTURE Clinical symptoms Increased number of unformed bowel movements 3, 6, 9 progression Leukocytosis Increased creatinine (1.5 x baseline) Decreased albumin Increased serum lactate Varying definitions of mild, moderate and severe disease based on above parameters Do not monitor by fecal leukocytes or related enzymes 21

22 THE CURRENT LABORATORY DIAGNOSIS OF CDI Glutamate Dehydrogenase (GDH) Enzyme Immunoassay (EIA) for Toxins A/B Laboratory Diagnosis Molecular Based (PCR Or LAMP)

23 RECOMMENDATIONS 2016 Acceptable strategies EIA for GDH and/or toxins A/B with a molecular assay for discrepant results A molecular test with or without a confirmatory toxin assay as long as results are coordinated with clinical data Unacceptable A stand-alone EIA for toxins A/B A stand alone EIA for GDH without a second test for positives 23

24 MOLECULAR TESTING INCREASES CDI With molecular tests, the number of CDI positive tests increases Important to only test patients with CSD Must differentiate between infection and colonization Sometimes this is very difficult to do Need for toxin assay on +PCR Is increased detection of carriers important? Isolation? IC says Yes Treatment? Most say No 24

25 ON THE HORIZON Screening asymptomatic patients on hospital admission 1 Ultra-sensitive toxin assays Point of Care assays 1. Longtin, Y. et al. JAMA Intern Med doi: /jamainternmed

26 CASE STUDY: HOSPITAL STORY Lynda Caine, RN, BSN, MPH, CIC, Infection Prevention Officer Concord Hospital 11:25 11:40 AM 26

27 ABOUT US Concord Hospital is a 238 bed acute care hospital located in the capitol of New Hampshire 2015 Patient Days = 65, Patient Admissions = 14,005 27

28 NHSN TAP TARGETED ASSESSMENT FOR PREVENTION NHSN Targeted Assessment for Prevention and Cumulative Attributable Difference (CAD) CAD is the number of infections that must be prevented to achieve an HAI reduction goal Year Total Patient Days HO Cases Num Exp CDI CAD SIR

29 C. DIFF BUNDLE - TESTS OF CHANGE Hand Hygiene Be Seen and HEARD Being Clean Environmental Cleaning Stool Specimens for C. difficile Antimicrobial Stewardship Fecal Microbial Transplant 29

30 HAND HYGIENE BE SEEN AND HEARD Hand Hygiene Be Seen and HEARD Being Clean We TELL our patients we clean our hands. Patients should NEVER have to ask if we cleaned our hands Press Ganey patient satisfaction question and Hand Hygiene Auditor question to random patients: Did you see or hear staff cleaning their hands? 30

31 HAND HYGIENE BE SEEN AND HEARD Hand Hygiene Be Seen and HEARD Being Clean 31

32 ENVIRONMENTAL CLEANING C. difficile think fecal veneer and cloud of feces! Clean Things clean and disinfect reusable equipment WITH BLEACH WIPES Use UV machine for patient bathroom on a daily basis Use UV machine after terminal cleaning at patient discharge 32

33 ENVIRONMENTAL SUPERVISOR AUDITS Just Culture and JIT Feedback to ES Staff If cleaning breach - icare forms are filled out and used to trend ES Managers do QA inspections two per month/per ES staff member ES Managers use Black Light to check high touch surfaces ES Managers use Weekly Staff Huddles to review and discuss competency 33

34 STOOL SPECIMENS FOR C. DIFF Micro Lab rejects ALL unformed stool specimens Aim to quickly get test for C. diff whenever admitted patients have diarrhea before day 3! 34

35 ANTIBIOTIC STEWARDSHIP Antimicrobial Stewardship Team - meet monthly Pharmacy Physician Champion Infectious Disease Physician Champion Pharmacists Infection Prevention Microbiology NE QIN-QIO MISSION: Coordinated interventions designed to improve and measure the appropriate use of antibiotic agents by promoting the selection of the optimal antibiotic drug regimen including dosing, duration of therapy, and route of administration 35

36 ANTIBIOTIC STEWARDSHIP Antimicrobial Stewardship Team Benefits Improved patient outcomes Reduced adverse effects including C. difficile colitis Improvement in rates of antibiotic susceptibilities to targeted antibiotics Optimization of resource utilization across the continuum of care, includes cost savings 36

37 Carefusion MedMined Data Mining Software 37

38 ANTIBIOTIC STEWARDSHIP - ICU ROUNDS 6 week Pilot Program, started May 9, 2016 Joint effort between the ICU pharmacists and Infectious Disease Physician Champion Formal review in MedMined of ICU patients on antimicrobials or with an infectious clinical picture on Mondays and Thursdays Separate from the infectious disease consultation service A form is placed in the chart in the progress note section outlining suggestions, which is NOT a part of the patient medical record Suggestions are not mandatory - it s up to the discretion of the provider to follow them Recommendations for urgent interventions are discussed directly with the primary provider NOTE RECOMMENDATIONS HAVE BE VERY WELL RECEIVED! 38

39 FECAL MICROBIAL TRANSPLANT - FMT FMT, or stool transplant, is the process of transplantation of fecal material from a healthy donor into a recipient with C. diff FMT involves restoration of the gut microflora by introducing healthy bacterial flora through: Enema (65% success rate), Colonoscopy (89-95% success rate), Nasogastric tube (76-81% success rate) or Orally capsule containing freezedried material It was a year-long process to bring FMT to Concord Hospital 7/9/15 First FMT performed at Concord Hospital 39

40 FMT DONOR PROCESS Donors are years old with BMI <30, no recent travel abroad and able to make daily deposits for 2 months Donor deposits quarantined for 60 days in between two full panel screens at a CLIA certified lab Processed with chunks removed Bottled and frozen Shipped on dry ice Kept frozen from at either -20 degrees C for 6 months or -80 degrees C for 24 months (bone freezer) 40

41 SUMMARY No One Intervention rather a C. diff Prevention Bundle Ongoing and Never Ending Process Questions? Lynda Caine, Infection Prevention Officer lcaine@crhc.org 41

42 WHAT THE INFECTION PREVENTIONIST NEEDS TO KNOW ABOUT ANTIBIOTIC STEWARDSHIP Keith Kaye, MD, MPH, Corporate Medical Director, Infection Prevention, Epidemiology and Antibiotic Stewardship, Detroit Med. Center 11:25 11:40 42

43 Antimicrobial Stewardship: What the Infection Preventionist Needs to Know Keith S. Kaye, MD, MPH Corporate Vice President of Quality and Patient Safety Corporate Medical Director, Infection Prevention, Hospital Epidemiology and Antimicrobial Stewardship Detroit Medical Center and Wayne State University Detroit, MI

44 OVERVIEW What is antimicrobial stewardship goals and structure TJC and CMS How can infection prevention and control interface and collaborate with antimicrobial stewardship?

45 Antimicrobial Stewardship Appropriate use of antimicrobials The right agent, dose, timing, duration, route Optimize clinical outcomes Optimize time to effective therapy Limit drug-related adverse events Minimize risk of unintentional consequences Help reduce antimicrobial resistance The combination of effective antimicrobial stewardship and infection control has been shown to limit the emergence of antimicrobial-resistant bacteria Dellit TH et al. Clin Infect Dis. 2007;44(2): Drew RH. J Manag Care Pharm. 2009;15(2 Suppl):S18 S23; Drew RH et al. Pharmacotherapy. 2009;29(5): ; Barlam et al, Clin Infect Dis, 2016, epub

46 Key Members of the Team Two major components: a) expertise and leadership and b) key stakeholders/major users/local leaders Experts and Hospital Leadership Infectious Diseases physician(s) (compensated) ID Pharmacist (compensated) Microbiology Administration (support, agree with metrics and goals) Informatics support Key stakeholders/major users/local leaders Critical Care Emergency Medicine Infection Prevention/Control Nursing Clinical pharmacy Hospitalists P and T

47 Core Elements of Stewardship Accountability Drug expertise - Appointing a single pharmacist leader Action - Implementing one or more of of the following Antibiotic time-out Prospective audit Restriction Tracking Reporting Education 47

48 National Action Plan to Combat Antibiotic-Resistant Bacteria (CARB) Published March, 2015 by President Obama Goals include: To make antimicrobial stewardship a condition of participation from CMS in line with CDC Core Elements of Hospital Antibiotic Stewardship Programs Establishment of antibiotic stewardship programs in all acute care hospitals and improved antibiotic stewardship across all healthcare settings by 2020 Reduction of inappropriate antibiotic use by 50% in outpatient settings and by 20% in inpatient settings by

49 Joint Commission and Antimicrobial Resistance Increasing focus and interest related to antimicrobial resistance Expect more (and more) regulation in the near future Note: CLABSI, CAUTI and SSI are other NPSGs

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52 INFECTION CONTROL ANTIMICROBIAL STEWARDSHIP COLLABORATION OPPORTUNITIES Influenza/emerging infections Device-related infections Abx resistance/c. diff Operative care Bloodborne fluid exposures Regulatory/accreditation QI/Patient Safety Ambulatory care Communicable diseases Tuberculosis Environment HAC/CMS

53 Several Infection Prevention and Stewardship Outcome Measures Used in Both VBP and HAC Payment Programs Measure Date Reporting Began VBP Program (1 st fiscal year) HAC Reduction Program (1 st fiscal year) CLABSI 2011 Q CAUTI 2012 Q SSI 2012 Q MRSA 2013 Q C.Diff 2013 Q AHRQ Composite ( PSI 90 ) (CMS calculates) Performance Periods 2015 VBP = CY VBP = CY VBP = CY VBP = CY

54 CMS LABID EVENTS MRSA prevention Antimicrobial interventions (e.g., eliminating unnecessary fluoroquinolone use) Pre-operative screening, decolonization, antimicrobial prophylaxis C. difficile infection Diagnostics Avoiding antimicrobial overuse

55 Clostridium difficile Infection (CDI) Antimicrobial stewardship is a critical component to CDI prevention and management Successful bundles for CDI prevention have combined antimicrobial stewardship and core infection prevention processes CDI reaching new levels of focus from clinicians and administration Aldeyab, J Antimicrob Chemother, 2012; Talpaert, J Antmicrob Chemother, 2011

56 Stewardship was part of multi-faceted bundle

57 OTHER CMS-RELATED COLLABORATIVE OPPORTUNITIES Pneumonia core measures Blood cultures Appropriate antimicrobials Readmissions (Pneumonia) Central-line associated bloodstream infection Appropriate culturing avoiding cultures drawn through the catheter, avoiding unnecessary blood cultures Catheter-associated urinary tract infection Avoiding unnecessary cultures of urine Avoiding unnecessary treatment of asymptomatic bacteruria

58 OPERATIVE CARE Prevention of surgical site infection Orthopedic (implant) surgeries (HPRO, KPRO) CABG Bariatric surgery Prevention of surgical site infection due to MRSA Role of antimicrobial stewardship team Appropriate antimicrobial prophylaxis dosing (and re-dosing) Pre-operative screening for S. aureus and decolonization/changes in antimicrobial prophylaxis

59 ANTIMICROBIAL RESISTANCE Minimizing unnecessary antimicrobial use can prevent the emergence and spread of multi-drug resistant (MDR) Gram-negative bacilli ESBL-producers Carbapenem-resistant enterobacteriaceae MDR Pseudomonas aeruginosa MDR Acinetobacter baumannii Methods Treatment guidelines and protocols De-escalation Short durations of therapy Dellit TH et al. Clin Infect Dis. 2007;44: Paterson DL et al. Clin Infect Dis. 2008;47(suppl 1):S14-20 Craven DE et al. Shorter course antibiotic therapy. In: Owens and Lautenbach, eds. Antimicrobial Resistance. Informa Healthcare, NY; 2008 File T. Clin Infect Dis. 2004;39(Suppl 3):S Marchaim, Infect Control Hosp Epidemiol. 2012;33(8):817-30

60 It s Not Just Carbapenems! Risk for Overall Antimicrobial Exposures and CRE CRE vs Uninfected OR (95% CI) CRE vs ESBL OR (95% CI) CRE vs Susceptible OR (95% CI) CRE vs all controls combined OR (95% CI) Antibiotic exposure in previous 3 months 11.4 (2-64.3) 5.2 ( ) 12.3 (3.3-45) Marchaim D, et.al. Infect Control Hosp Epidemiol. 2012;8: ( ) 91 unique patients with CRE were included. Exposure to antibiotics within 3 months was an independent predictor that characterized patients with CRE isolation in all analyses

61 NAVIGATING THE POLITICAL LANDSCAPE As Antimicrobial Stewardship emerges as a formal part of quality improvement and hospital infrastructure, personnel will increasingly be drawn into hospital reporting, multi-disciplinary interactions and politics Infection control can assist antimicrobial stewardship with Understanding lines of reporting Business case and ROI development Identifying and avoiding political landmines Identifying and interacting with influential administrators, clinicians, thought leaders Who to avoid Timelines and processes for development and implementation of protocols, guidelines, interventions, changes in practice/culture

62 CONCLUSIONS Antimicrobial stewardship is here to stay- CMS conditions of participation coming in 2017 Infection control is well established in hospital culture and infrastructure Antimicrobial stewardship is emerging and increasingly recognized and valued Many opportunities for fruitful collaborations and interactions between infection control and antimicrobial stewardship Antimicrobial resistance and C. difficile Device-associated infections CMS reporting and VBP Antimicrobial stewardship can learn much from infection control with regards to navigating the political healthcare landscape

63 Questions?

64 BRING IT HOME Mallory Bender, Program Manager, HRET 11:55 12:00 64

65 PHYSICIAN LEADER ACTION ITEMS What are you going to do by next Tuesday? Meet with Pharmacy and Infection Prevention. Are your antibiotic stewardship goals aligned? Talk to a few colleagues. Assess their understanding of when stools for C diff should be ordered. What are you going to do in the next month? Find champions and collaborate with Pharmacy and IP s to address the barriers to improved antibiotic stewardship Work with nursing to develop a protocol that prevents stools from being automatically sent for C diff if the patient has recently been started on tube feedings or has recently been given an enema or a laxative. 65

66 UNIT-BASED TEAM ACTION ITEMS What are you going to do by next Tuesday? Discuss the Brecher Guidelines at shift briefings. Assess understanding. Encourage discussion with the IP when any question exists as to whether to send the stool or not. What are you going to do in the next month? Work to develop a protocol that prevents stools from being automatically sent for C diff if the patient has recently been started on tube feedings or has recently been given an enema or laxative. Work with physicians, nurses, and IPs to develop nurse scripting for reporting of loose stools to physicians and IPs to better engage all in the diagnostic steps for accurately identifying CDI. 66

67 HOSPITAL LEADERS ACTION ITEMS What are you going to do by next Tuesday? Understand the C diff harm rates in your hospital. Talk to the physician, pharmacy, and IP leaders to better understand the current status of antibiotic stewardship in your hospital. What are you going to do in the next month? During Leadership walk rounds, discuss and understand your staff s current knowledge of C diff diagnosis. Compare the information gleaned from walk rounds with best practices learned from this webinar and at the website. Create a plan to close the gaps between your practices and best practices. 67

68 PFE LEADS ACTION ITEMS What are you going to do by next Tuesday? Find a patient story of hospital acquired CDI. Discuss this story with leaders. Make it real. What are you going to do in the next month? Assess your organization s efforts to educate patients and families about antibiotics to reduce unnecessary demand. Using patient CDI stories, smartly push forward the efforts to improve antibiotic stewardship. 68

69 UPCOMING EVENTS PfP Pacing Event Serving Patients Engaged in the Digital Universe Webinar: June 30, :00pm - 3:00pm (CDT) AHA/HRET HEN 2.0 QI Office Hours: Sepsis Project Focus Webinar: July 6, :00am - 12:00pm (CDT) AHA/HRET HEN 2.0 Webinar Falls Follow Up: Strategies to Balance Safety, Privacy and Mobility Webinar: July 7, :00am - 12:00pm (CST) Register Now! 69

70 THANK YOU! Find more information on our website: Questions/Comments: 70