the Presentation Slides

HEN 2.0 C.DIFF WEBINAR
SENDING STOOLS,
MANAGING ANTIBIOTICS,
AND OTHER PRACTICAL INFORMATION
June 30, 2016
11:00 a.m. – 12:00 p.m. CT
1
WELCOME AND INTRODUCTIONS
Mallory Bender, Program Manager | HRET | 11:00 – 11:05
2
AGENDA FOR TODAY
3
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
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
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
HEN DATA UPDATE
Richard Rodriguez, Data Analyst | HRET | 11:05 – 11:10 AM
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C. DIFFICILE : HEN 2.0 EVALUATION MEASURES
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C. DIFFICILE : HEN 2.0 EVALUATION MEASURES
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HEN 2.0 C. DIFFICILE RATE
Data submitted to
AHA/HRET as of:
5/27/2016
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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
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
ACUTE INFECTIOUS DIARRHEA1
179 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. 2014. 370: 1532-40
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“BURDEN OF CDI IN THE US”1
• 2011 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. 2015 372: 825-834
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Who Should I Test?
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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
GOALS OF TESTING
• Identify cases of CDI and rule out CDI in patients with diarrhea1
• 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 2012. 55: 982-989
17
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”?
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WHAT TO TEST
THE BRECHER GUIDELINES1
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. 2013. CID.57:1175-1181
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What Clinical Symptoms Help
Determine if the Patient has CDI?
20
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
THE CURRENT LABORATORY
DIAGNOSIS OF CDI
Glutamate
Dehydrogenase (GDH)
Enzyme Immunoassay (EIA) for
Toxins A/B
Laboratory
Diagnosis
Molecular Based (PCR Or LAMP)
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
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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
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ON THE HORIZON
• Screening asymptomatic patients on hospital admission1
• Ultra-sensitive toxin assays
• Point of Care assays
1. Longtin, Y. et al. JAMA Intern Med doi:10.1001/jamainternmed.2016.0177
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CASE STUDY: HOSPITAL STORY
Lynda Caine, RN, BSN, MPH, CIC, Infection Prevention Officer
Concord Hospital |11:25 – 11:40 AM
26
ABOUT US
• Concord Hospital is a 238 bed acute care hospital located in the
capitol of New Hampshire
• 2015 Patient Days = 65,020
• 2015 Patient Admissions = 14,005
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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
2012
28303
21
21.499
6
1
2013
58592
36
43.398
5.6
0.8
2014
60539
41
45.884
8.9
0.9
2015
59565
27
44.287
-4
0.6
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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
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
HAND HYGIENE – BE SEEN AND HEARD…
• Hand Hygiene – “Be Seen and HEARD Being Clean”
31
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
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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
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!
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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
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
Carefusion MedMined Data Mining Software
37
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
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
FMT – DONOR PROCESS
• Donors are 18-50 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)
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SUMMARY
•
•
No One Intervention – rather a C. diff Prevention Bundle
Ongoing and Never Ending Process
•
•
Questions?
Lynda Caine, Infection Prevention Officer [email protected]
41
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
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
OVERVIEW
• What is antimicrobial stewardship goals and structure
• TJC and CMS
• How can infection prevention and control interface and collaborate with
antimicrobial stewardship?
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):159–177
Drew RH. J Manag Care Pharm. 2009;15(2 Suppl):S18–S23;
Drew RH et al. Pharmacotherapy. 2009;29(5):593–607;
Barlam et al, Clin Infect Dis, 2016, epub
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
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
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 2020
https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-nationalaction-plan-combat-ant
Joint Commission and Antimicrobial
Resistance
• Increasing focus and interest related to antimicrobial resistance
• Expect more (and more) regulation in the near future
https://www.jointcommission.org/assets/1/6/2016_NPSG_HAP.pdf
Note: CLABSI, CAUTI and SSI are other NPSGs
https://www.jointcommission.org/assets/1/6/HAP-CAH_Antimicrobial_Prepub.pdf
INFECTION CONTROL – ANTIMICROBIAL
STEWARDSHIP COLLABORATION OPPORTUNITIES
Influenza/emerging infections
Device-related infections
Operative care
Regulatory/accreditation
Ambulatory care
Abx resistance/C. diff
Bloodborne fluid exposures
QI/Patient Safety
Communicable diseases
Tuberculosis
Environment
HAC/CMS
Several Infection Prevention – and Stewardship
Outcome Measures Used in Both VBP and HAC Payment Programs
Measure
Date Reporting
Began
VBP Program
(1st fiscal year)
HAC Reduction
Program
(1st fiscal year)
CLABSI
2011 Q1
2015
2015
CAUTI
2012 Q1
2015
2015
SSI
2012 Q1
2016
2016
MRSA
2013 Q1
C.Diff
2013 Q1
AHRQ
Composite (“PSI
90”)
Performance Periods
2015 VBP = CY 2013
2016 VBP = CY 2014
2017 VBP = CY 2015
2018 VBP = CY 2016
(CMS calculates)
2017
2015
2017
2017
2015
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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
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
Stewardship was part of multi-faceted bundle
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
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
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;44:159-177
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):S159-164
Marchaim, Infect Control Hosp Epidemiol. 2012;33(8):817-30
It’s Not Just Carbapenems!
Risk for Overall Antimicrobial Exposures and CRE
CRE vs
CRE vs
Uninfected
ESBL
OR (95% CI) OR (95%
CI)
Antibiotic
exposure in
previous 3
months
11.4
(2-64.3)
CRE vs
Susceptible
OR (95%
CI)
5.2
12.3
(1.4 19.4) (3.3-45)
CRE vs all
controls
combined
OR (95%
CI)
7.1
(1.9-25.8)
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
Marchaim D, et.al. Infect Control Hosp Epidemiol. 2012;8: 817-30
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
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
Questions?
BRING IT HOME
Mallory Bender, Program Manager, HRET| 11:55 – 12:00
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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
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.
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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 www.hret-hen.org
website. Create a plan to close the gaps between your practices and
best practices.
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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.
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UPCOMING EVENTS
• PfP Pacing Event | Serving Patients Engaged in the Digital Universe
Webinar: June 30, 2016 2:00pm - 3:00pm (CDT)
• AHA/HRET HEN 2.0 | QI Office Hours: Sepsis Project Focus Webinar:
July 6, 2016 11:00am - 12:00pm (CDT)
• AHA/HRET HEN 2.0 Webinar | Falls Follow Up: Strategies to Balance
Safety, Privacy and Mobility Webinar: July 7, 2016 11:00am - 12:00pm
(CST)
Register Now! http://www.hret-hen.org/events/index.dhtml
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THANK YOU!
Find more information on our website: www.hret-hen.org
Questions/Comments: [email protected]
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