C Diff: Evidence Based Strategies for Source Control

C Diff: Evidence Based Strategies for Source Control Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist / Educator / Consultant ADVANCING NURSING kvollman@comcast.net Northville Michigan www.vollman.com ADVANCING NURSING LLC 2017

Disclosures for Kathleen Vollman Consultant Michigan Hospital Association Keystone Center Consultant/Faculty for CUSP for MVP AHRQ funded national study Subject matter expert for CAUTI and CLABSI for CMS/HEN 1.0 & 2.0 Consultant and speaker bureau for Sage Products LLC Consultant and speaker bureau for Hill Rom Inc Consultant and speaker bureau for Eloquest Healthcare

Objectives for the Day Identify risk factors for the development of C Diff Discuss strategies within and beyond the bundle to sustain reduction or elimination C Diff Shape strategies for implementation and address challenges Outline a test of change for your organizaiton

Notes on Hospitals: 1859 It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. Florence Nightingale Advocacy = Safety

Protect The Patient From Bad Things Happening on Your Watch

Interventional Patient Hygiene Hygiene the science and practice of the establishment and maintenance of health Interventional Patient Hygiene.nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies Central line catheter insertion and maintenance program

INTERVENTIONAL PATIENT HYGIENE(IPH) VAP/HAP Oral Care/ Mobility Catheter Care HAND HYGIENE CLEAN GLOVES Patient PATIENT CLEAN GLOVES HAND HYGIENE Skin Care/ Bathing/Mobility CA UTI CA BSI SSI Falls HASI Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

Achieving the Use of the Evidence Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152 154 Value Attitude & Accountability NSO

Building Resiliency Into Interventions Forcing functions and constraints Automation and computerization Strongest Standardization and protocols Checklists and independent check systems STRENGTH OF INTERVENTION Rules and policies Education and information 9 Weakest Vague warnings Be more careful!

Why HAI's? Protecting Patients From Harm Estimates: 183 Hospitals in 10 States HAI: 722,000/year HAI-related deaths: 75,000/year Hospitalized patients develop infection: 1 out of 25 (4%) Death due to sepsis/septic shock: 700/day Money spent: $45 billion/year Increase risk of 27days vs. 59 days readmission: Magill SS, et al. New England Journal of Med, 2014;370:1198-208

Hospital Performance Based Payments Hospital Acquired Conditions 1% reduction to total DRG payments CLA BSI, CAUTI & C diff 2018 expanded to wards 8% of Based DRG Payments at Risk by 2017 EMR Meaningful Use Requirements Reductions up to ¾ of update factor Readmissions 3% reduction CLA BSI, CAUTI & C diff Value Based Purchasing (VBP) 2% reduction CAUTI & CLA BSI

Economic Burden of HAI s: Build The Business Case Generated point estimates for attributable cost & LOS 5 Major Infections=9.8 billion SSI s, CLABSI s, VAP/VAE, CAUTI s, C Diff SSI s (33.7%) VAP (31.6%) CLA BSI (18.9%) C Diff (15.4%) CA UTI <1% Zimlichman E, et al. JAMA Intern Med, 2013; 173:2039-46 Per Case Basis SSI CLABSI VAP CAUTI C Diff 50% HAI s Preventable $20,785 $45,814 $40,144 $896 $11,285

Strategies to Decrease C diff

What is C diff?

C diff Clostridium difficile (C. difficile) is an anaerobic, spore forming bacteria spread through fecal oral transmission C. difficile infection (CDI) colonizes the large intestine and releases two toxins Causes a number of illnesses; diarrhea, colitis and sepsis. Transmission: contaminated environments and health care personnel hands Antimicrobial therapy most important risk factor for CDI infection longer courses multiple antibiotics Fluoroquinolones the risk. Other drug may disrupt colonic flora; gastric acid suppression*, chemotherapy Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org. Howell MD, et al. Arch Intern Med. 2010;170(9):784 790

HAI s in the US: Point Prevalence Estimates: 183 Hospitals in 10 States HAI: 722,000/year HAI-related deaths: 75,000/year Hospitalized patients develop infection: 1 out of 25 (4%) Death due to sepsis/septic shock: 700/day Money spent: $45 billion/year Increase risk of 27days vs. 59 days readmission: Magill SS, et al. New England Journal of Med, 2014;370:1198-208

CDI contributed to half of a million infections and directly led to approximately 15,000 deaths in one year Magill SS et al. NEJM 2014;370:1198 208

NHSN Definitions Healthcare Facility Onset (HO): > 3 days after admission Community Onset (CO): Inpatient <3 days after admission Community Onset Healthcare Facility Associated: Patient discharged from HCF < 4 weeks prior Standardized Infection Ratio (Goal < 1) SIR = # HO CDI Observed # HO CDI Expected

Burden of Clostridium difficile Infection in the United States Magnitude of CDI in the US continues to evolve Estimated # of CDI infections was 453,000 in 2011 Persons > 65 years (RR 8.65; 95% CI (8.16, 9.31) Estimated 29,300 deaths in 2011 2.4 to 8.9 deaths per 100,000 ¼ come from hospitals, remainder nursing homes and community settings Lessa FC, et al. N Engl J Med 2015;372:825 34.

Clostridium difficile Infection is Costly Attributable cost/patient: $6,100 11,300 Associated with longer length of stay (~3 days increase) and readmissions (22% under 30 days) CDI reoccurs in 15 35% of pts with 1 previous event, 33 65% in pts with > 2 episodes of CDI Publicly reported Costs related to CDI are estimated at $4.8 billion for acute care facilities alone Rates linked to the Hospital Acquired Condition (HAC) and Value Based Purchasing (VBP) programs Dubberke ER, et al. Clin Infect Dis 2012;55:S88 92; Zimlichman E, et al. JAMA Intern Med 2013;173(22):2039 46 Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org. Butler M,et al. Early Diagnosis, Prevention, and Treatment of Clostridium difficile: Update. Comparative Effectiveness Review No. 172. AHRQ Publication No. 16 EHC012 EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. Deshpande A, et al. Am J of Infect Control. 2017 in press

C Diff Infections in Surgical Patients Single center study, 600 bed tertiary, academic medical center Retrospective review over 4 month period, patient had surgery (othro, neuro, trauma and general) + for HA C diff (3 days post admission, 12weeks post discharge Multivariable analysis of surgical patient risk factors Results: 52 cases 0.80 cases per/1000 pt days Risk factors: ASA classification of 4 5/ 15 fold, pervious 6 month an bio c use a 2.2 fold, Periopera ve an bio c beyond 24hrs a 3.34 fold, number of admission in the past yr. Bernatz JT, et al. Infect Control Hosp Epidemiol 2017;38:1254 1257

HHS SIR Goal: 0.7 HIIN Network Goal: 20% Reduction

CDI Prevention Efforts Should Focus on Community and Facility based Antimicrobial Stewardship and Preventing Disease & Transmission.

Gap Analysis

Tier 1: First Steps to Address C. diff. C. diff surveillance Appropriate & timely testing of suspect cases > 3 days HO, <3 day CO Appropriate testing Clinically significant diarrhea without other obvious causes. Use recommended stepwise testing method Antibiotic Stewardship Eliminate unnecessary antibiotic use Use antibiotics with lower risk for promoting CDI Contact Precautions; order at time of ordering C. diff. test Hand Hygiene Glove and Gown use Patient specific equipment and disinfection prior to use with others Effective and thorough cleaning and disinfection processes Effective Hand Hygiene Program Environmental Cleaning

Stewardship and CDI Testing Only test symptomatic patients >3 unformed stools per day within 1 to 2 days Lab should refuse formed stools test Asymptomatic colonization rates high (10%) Don t test if received laxatives within past 24 hrs Don t retest within 7 days/lab hard stop Discontinue test if not collected within 24 hrs Time of test = placement into contact precautions Timely recognition of symptoms Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org. Dubberke ER, et al. Infection Control and Hospital Epidemiology, 2014;35(6):628 645

Strategies for CDI Testing Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org.

CDI Testing Rapid diagnosis will lead to prompt treatment & implementation of contact precautions that can limit the spread of CDI in the environment of care Polymerase chain reaction (PCR) tests have a sensitivity of 90 percent or greater and a specificity of 95 percent or greater Some facilities use a two step approach as a method of detection: 1) the stool is first tested for GDH and toxins and 2) indeterminate results then undergo PCR analysis. CDI is a clinical Diagnosis; no test makes the diagnosis of CDI Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org.

Antibiotic Stewardship Program that promotes appropriate selection, dose, route and duration of antimicrobial therapy Primary goal: optimize clinical outcomes while reducing unintended consequences of antimicrobial use Toxicity colonization of pathogenic organisms Antibiotic resistance Secondary goal: reduce health care costs associated with diseases such as CDI and antimicrobial resistance. Comprehensive programs both large & small hospitals shown in an microbial use between 22% 36% with annual savings of $200,000 to $900,000. Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org.

Antibiotic Use: What s The Issue 30% to 50% of all antibiotic use is inappropriate Inappropriate use includes: Longer than necessary duration of therapy Treatment of nonbacterial diseases Treatment of contaminants or colonizers Meaningless duplicate therapy (e.g., treatment with multiple antibiotics targeting anaerobes simultaneously) Monitoring and analyzing antimicrobial use by disease, unit and practitioner can increase organizational knowledge of opportunities for stewardship Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org.

Antibiotic Use Among 323 U.S. Hospitals Model estimates that 30% reduction in use of broad-spectrum antibiotics will result in a 26% reduction in CDI. Greatest Risk MMWR March 7, 2014 / 63(09);194 200

Receipt of antibiotics in prior patients was significantly associated with incident CDI in subsequent patients (log rank P <.01) This relationship remained unchanged after adjusting for other factors known to influence risk for CDI (receipt of antibiotics by the subsequent patient, prior patients developed CDI).

England s Experience Key Points Significant reduction in hospital quinolone use was associated with a near eradication of quinolone R C. difficile (67% resistance to 3%) Quinolone R strains did not re emerge after an increase in quinolone use Cephalosporin restriction and enhanced infection control was not responsible for the demonstrated reduction in CDI given lack of decrease in quinolone S C. difficile

Key Prevention Action Steps Monitor Healthcare Effectiveness Data and Information Set (HEDIS) performance measures on antibiotic utilization in pharyngitis, upper respiratory infections and acute bronchitis. Eliminate (1) Remove redundant unnecessary combination antibiotics antimicrobial from therapy Adopt formulary, guidelines (2) for restrict managing options CAP using for a duplicate shorter course Educate antibiotics prescribing and clinicians antibiotics about for appropriate special selection, use dose, circumstances, timing and duration (3) provide of treatment ongoing surveillance of Focus antibiotic efforts on use reducing by pharmacy, the use of and certain (4) antibiotic escalate classes to associated physician with leaders CDI, such as as necessary all cephalosporins, of clindamycin which leads and fluoroquinolones to improved accuracy of antibiotic use. Limiting the formulary and requiring pre authorization for certain antibiotics is a key strategy in reducing unnecessary use of antibiotics Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org.

Proper Hand Hygiene and disinfection of surfaces can help prevent the spread of C diff. 2017 Trinity Health 37

Hand Hygiene is the Single Most Important Factor in Preventing the Spread of Infection Jullian Desayes I, et al American Journal of Infection Control 45 (2017) 51 8

Guidelines for Hand Hygiene in Health Care Settings If hands are not visibly soiled, use an alcohol based hand rub 62% for routinely decontaminating hands in all other clinical situations (20 30 seconds) (II) When hands visibly soiled or exposure to potential spore forming organisms, wash with either a non antimicrobial or antimicrobial soap & water (40 60 seconds) (II). Can still use ABH in non outbreak C diff settings Do not use Triclosan containing soaps Use gloves with CDI Decontaminate hands after removing gloves Provide HCW with hand lotions & creams to minimize occurrence of irritant contact dermatitis Use multidimensional strategies to improve hand hygiene practice (IA) Do not wear artificial fingernails or extenders CDC. Hand Hygiene Guidelines: MMWR 2002; 51(No. RR-16):[1-45] WHO Hand Hygiene Guidelines 2009 Ellingson K, et al. Infect control & Hosp Epidemiology, 2014;35(2): S155-S178

When to Wash Wash In Wash Out Similar rates of HH compliance Sunkesula VCK, et al AJIC, 2015;43:16019 Pittet D. Infect Control Hosp Epidemiol, 2009;30(7):611-622 WHO Hand Hygiene Guidelines 2009 Ellingson K, et al. Infect control & Hosp Epidemiology, 2014;35(2): S155-S178

Key Components to Multimodal Strategy to Improve Adherence (II) Education & motivation & strong commitment to improve hand hygiene by frontline workers & leadership (Institutional safety climate Engage staff in the process Simply & standardize Alcohol based hand rub as primary method for hand hygiene.right product C diff wear gloves & gown/both methods of hand hygiene are not real effective Reminders in the workplace/red line approach Verified by competency, monitored compliance and feedback/weekly initially (II) WHO Guidelines 2009 Pittet D. Infect Control & Hosp Epidemio, 2008;29:957-959 Sax, H., et. al. Infection Control and Hospital Epidemiology 2009, 28, 1267-1274 Erasmus, V. et. Infection Control and Hospital Epidemiology.2009 30(5), 415-419 Bonuel N, et al. Critical Care Nursing Quarterly, 2009;32:144-148 Ellingson K, et al. Infect Control & Hosp Epidemiol, 2014;35(S2):S155-178

Catchy & Emotional Signs

Hand Hygiene Measurement Methods Direct Observation Srigley et al demonstrated, in 2014, that HCWs were 3x more likely to clean hands when in the line of sight of a direct observer! A 300% Hawthorne Effect Product Usage/Volume Automation monitoring can improve compliance Electronic versus direct observation more accurate in measuring compliance Morgan DJ, et al. AJIC, 2012;40:955 959 Haas and Larson Journal of Hospital Infection 2007;66:6-14 Polgreen PM, et al. Infect Control & Hosp Epidemiol, 2010;31:1294-1297 Ellingson K, et al. Infect Control & Hosp Epidemiol, 2014;35(S2):S155-178

3 Types of Electronic Monitoring Group Monitoring Non Badge Based Individual or Group Monitoring Badge Based (Stand Alone) Individual or Group Monitoring Badge Based Enabled with a Real Time Locating System (RTLS) Infrastructure Capable of Capturing 100% of HHEs and Eliminating the Hawthorne Effect along with the Practice of Secret Shoppers Seeing Non Compliance and Allowing Care to Proceed Anyway

Contact Precautions Order at time of ordering C. diff. test Hand Hygiene Glove and Gown use Patient specific equipment and disinfection prior to use with others Use disposable equipment or dedicate equipment to a single patient (e.g., blood pressure cuffs, thermometers, commodes). Use commode liners to limit splashing or contamination when emptying Effective and thorough cleaning and disinfection processes Define who is responsible for cleaning ventilators, IV pumps and other critical patient care equipment. Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org.

The Environment: What is the Problem? All these studies found a patient is at increased risk of picking up pathogens like, MRSA, VRE, & C. diff. when admitted to room where prior patient had one of these Huang SS (2006) 1 Drees M (2008) 2 Zhou Q (2008) 3 Moore C (2008) 4 Hamel M (2010) 5 Shaughnessy et al. 2011 1. Huang SS, et al. Arch Intern Med. 2006;166(18):1945 1951. 2. Drees M, et al. Clin Infect Dis. 2008;46(5):678 685. 3. Zhou Q, et al. Infect Control Hosp Epidemiol. 2008;29(5):398 403. 4. Moore C, et al. Infect Control Hosp Epidemiol. 2008;29(7):600 606. 5. Hamel M, et al. Am J Infect Control. 2010;38(3):173 181.

C Diff Environmental Impact CDI spores can survive on surfaces for as long as five months. CDI spores were found in 49% of the hospital rooms occupied by patients diagnosed with CDI, 29 % of the rooms of asymptomatic CDI carriers The most heavily contaminated areas were hospital room floors, bed rails and bathrooms Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org.

Examples of High Frequency Touch Surfaces; Patient Room Use specialized privacy curtains that can be replaced without a ladder and appropriately cleaned & Attach disposable, plastic adhesive shields to privacy curtains to prevent glove or hand contact and contamination 2017 Trinity Health 50

Reducing the Load in the Environment: Cleaning of Patients Room Develop procedures for routine disinfection of environmental surfaces with an EPA registered sporicidal disinfectant 1 Use a 1:10 dilution of 5.25% sodium hypochlorite Use bucket method for appropriate kill time 2 Use audible timers to ensure appropriate contact time for cleaning agents Use bleach wipes as an adjunct 2 Use a two step cleaning protocol incorporating mobile, automated equipment that releases ultraviolet C radiation or hydrogen peroxide vapor 3,4 1. Siegel JD, et al. Available at: http://www.cdc gov/hicpac/pdf/isolation/isolation2007.pdf. Accessed April 4 th, 2013. 2. APIC s Guide to Preventing Clostridium difficile Infections (2013). Available at http://cdiff2013.site.apic.org/about the conference/new c diff guide. Accessed on April 4 th, 2013. 3. Nerandzic MM, et al. BMC Infect Dis 2010 Jul 8;10:197 4. Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret hiin.org.

Effect of Ultraviolet Light on C Diff Spore Recovery vs. Bleach Alone Evaluate effectiveness of manual cleaning and UV C on inpatient hospital room surfaces Measured CFUs on 9 high touch surfaces after bleach cleaning & after UV C cleaning 3 tower system. Bathroom done daily & inpatient room on discharge Bleach alone: 13% positive for C diff > 10 CFU s Bleach & UV C:.4% positive for C diff > 10 CFU s Toilet seat and over bed table most commonly + sites Liscynesky C, et al. Infect Control & Hospital Epidol. 2017;38(9):1116-1117

Oxycide [ECOLAB] Works on all surfaces One step cleaner, disinfectant and sporicidal Less chemicals=less cost Contact time is 3 min for C. difficile spores 5 min for HBV & HCV Two Active ingredients: PERACETIC ACID breaks down outer membrane of the spore, bacteria or virus HYDROGEN PEROXIDE destroys the inner component (DNA, proteins) Helps reduce risk and cost of replacing damaged goods. Does not corrode surfaces, damage mattresses or soft goods 2017 Trinity Health 53

Consider Stool Containment Potential to Reduce Skin Injury IAD is a type of irritant contact dermatitis (inflammation of the skin) IAD 5x more likely to develop a HAPU Reduce Exposure to Harmful Microorganisms Giuliana K. Presented at the CAACN September 25 27 th Winnipeg, Manitoba, CA Gray M. Presenting a Wound Care Conference, 2016, New York City, NY

2 Step Process for Fecal Containment If the rectum is intact Patient is neutropenic Stool culture negative If the perianal skin is not intact Stool culture positive

Evidence Based Review & Recommendations Jan 2009 to April 2015 3236 articles screened 261 meet criteria for review 46 studies included Quality 82% (QI MQCS) Results: Twice daily disinfection of high touch surfaces & terminal cleaning with chlorine based products CDI 45% to 85% Bundled interventions & antibiotic stewardship showed promise for CDI Louh IK, et al. Infect Control Hosp Epidemiol 2017;38:476 482

Tier 2: Enhanced Practices; Escalation of Tactics in Tier 1 Implemented but No Decrease Seen Define the opportunities for improvement Focused review of hospital onset C. diff. cases Consider prompt assessment & expedite specimen submission for testing; time to isolation? Same rooms versus different rooms? Review Antibiotic use Review Testing practices Check Timing of Contact precaution & compliance Shared equipment? Review type and practices around sporicidal surface disinfectant Consider supplemental disinfection strategies Intervene based on opportunities 58 found

HRET, C Diff Change Package, 2017

Driving Change Gap analysis Build the Will Protocol Development Structure Make it Prescriptive Overcoming barriers Daily Integration Process Outcomes

Thank You

Targeted Assessment for Prevention (TAP) Strategy Target Assess Prevent Target facilities/units using TAP Report function available in NHSN Assess gaps in infection prevention in targeted facilities/units using Facility Assessment Tools Prevent infections by implementing interventions to address the gaps using Implementation Guidance http://www.cdc.gov/hai/prevent/tap.html

http://www.cdc.gov/hai/prevent/tap.html

Using a Measure to Help Target Prevention Efforts to Reach HAI Reduction Goals: Cumulative Attributable Difference (CAD) CAD OBSERVED PREDICTED SIR target Target SIR can be chosen based on goals of a group, state, organization, or national target Lower target SIR larger CAD ( excess number of infections) NHSN uses HHS target SIRs CAD is the number of infections needed to prevent to reach the target SIR Courtesy of Minn Soe, CDC

Cumulative Attributable Difference (CAD) 8 Number Of Infections 7 6 5 4 3 2 1 0 7.0 Observed CAD = observed (predicted *0.55) = 4.96 3.7 Predicted

What Data/Information Do You Need So That You Can Decrease the Number of Infections at Your Facility? Infection rates and Device utilization ratios SIR for CAUTI, CLABSI and CDI Identified targets what SIR should you be striving for? (national, state or organization/health system specific Can use the CAD to help you understand how many infections you need to prevent

What Data/Information Do You Need So That You Can Decrease the Number of Infections at Your Facility? Gap analysis related to prevention practices What are the research supported prevention practices and which of these have you implemented? Process data How reliably are you performing each of the prevention practices? Learning from Defect When you have an infection taking a deep dive into finding out why it occurred?

Your Turn, Try a Test of Change Planning Worksheet SMALL TEST OF CHANGE WHAT do you need to test this idea? WHO will be involved in the tests? HOW will you inform participants? WHERE will the test occur? WHEN will the test occur? HOW will you know it is successful? When will you compare what happened to your prediction? When will you decide what to do next? SMALL TEST OF CHANGE What did you predict will happen? What happened? What did you learn? What are the next steps?

Table Exercise: Develop a Small Test of Change Look at your data: Gap Analysis: what evidence based interventions are you not doing? Process data: how well are you implementing all of the science Review evidence based practices and processes previously shared Identify one small test of change you would like to implement to improve your 3hr bundle sepsis compliance Complete Test of Change worksheet Share with group