Vahina o Vahiga

C. difficile
Infection Prevention and Control
Brian Koll, MD, FACP, FIDSA
Medical Director and Chief
Infection Prevention and Control, BIMC
Professor of Medicine, AECOM
Clostridium difficile (CDI)
McDonald LC, Owings M, Jernigan DB. Emerg Infect Dis 2006; 12:409-415.
Zilberg MD, Shorr AF, Kollef MH. Emerg Infect Dis 2008; 14:929-931.
Loo VG, Poirier L, Miller MA, et al. N Engl J Med 2005; 353:2442-2449.
Pepin J, Valiquette L, Cossette B. CMAJ 2005; 173:1037-1042.
Muto CA, Pokrywka M, Shutt K, et al. Infect Control Hosp Epidemiol 2005; 26:273-280.
• Approaches MRSA as the
most common cause of HAIs
in the United States
• The number of hospitalized
patients in the United States
with CDI has more than
doubled between 2000 and
2005
• With the emergence of the
BI/NAP/027 strain, increased
severity
and
mortality
associated with CDI
• Between 1999 and 2004,
CDI
mortality
rates
quadrupled from 5.7 to 23.7
deaths/million population
Clostridium difficile (CDI)
McDonald LC, Owings M, Jernigan DB. Emerg Infect Dis 2006; 12:409-415.
Zilberg MD, Shorr AF, Kollef MH. Emerg Infect Dis 2008; 14:929-931.
Loo VG, Poirier L, Miller MA, et al. N Engl J Med 2005; 353:2442-2449.
Pepin J, Valiquette L, Cossette B. CMAJ 2005; 173:1037-1042.
Muto CA, Pokrywka M, Shutt K, et al. Infect Control Hosp Epidemiol 2005; 26:273-280.
• Attributable mortality of 6.9%
at 30 days after diagnosis
and 16.7% at one year
• Mean increased length of
hospital stay of up to 4.5
days
• Attributable
costs
for
inpatient care estimated to
be as high as $6,326 per
episode
• Estimates of treating CDI
and its complications cost
the United States health care
system $3.2 billion annually
• Urgent need to implement
strategies for prevention of
CDI
Clostridium difficile (CDI)
• HHS National Targets for
Elimination of HAIs
• 30% reduction compared
to 2010
• CMS 10th Scope of Work
• 10% reduction by July
2014
• 2011 NYS DOH HAI Report
• Only 79% hospitals who
completed survey said
that the prevention and
control of CDI is a priority
at their hospital
NYS DOH HAI Report
HO CDI
8.5
8
HO
CDI
Rate 7.5
7
2010
2011
Clostridium difficile (CDI)
If Successful in Other Areas…
BIMC
5
4
NHSN Infection 3
Surveillance
Rate
2
CLABSI
MRSA
CDI
1
0
2004 - 2006
2008
Reducing CDI
• Prior model developed for teamwork and
communication to reduce central line
associated bloodstream infections and
healthcare acquired MRSA infections
• Interdisciplinary team involvement
• Use of checklists and infection prevention
bundles
• Bundle monitoring tool
• Environmental cleaning protocol checklist
Begins with Leadership
• Link infection prevention to
organizational strategy and
resources
• Link a culture of safety to
outcomes
• Engage
and
facilitate
teamwork
Begins with Leadership
• All Formal Authority Positions
• Chairs, Chiefs, Managers,
Directors, Supervisors
• All Physicians
• Informal Leaders
Begins with Leadership
Board of Trustees
Quality and Patient Safety Award
2010
Setting Goals
Measures
2012
Results
CDI
30% reduction
BIP 6.1
BIB 13.2
FY 2013
Benchmark Performance
Target
BIP 8.6
BIB 10.5
BIP 4.9
BIB 8.0
• Understandable
• Achievable
• Exceed when and if
possible
Inter-disciplinary Team Members
Physicians
• Medical Center President
• Chief Medical Officer
• Chief Quality Officer
• Associate Chairman, Department of
Medicine
• Director of Medical Residency Program
• Antibiotic Stewardship Physician
• Fellows, Residents and Interns
• Medical Students
Infection Control
• Hospital Epidemiologist
• Manager
• Practitioner
Patient Care Services
• Chief Nursing Officer
• Vice President and Director
• Nurse Manager
• Nurse Education Manager
• Nurses
• New Nurses
• Nursing Students
• Nursing Assistants
Other
• Director
•
•
•
•
•
•
•
Materials Management
Housekeeping
Quality Improvement
Pharmacist
Pharmacy Intern
Transport Services
Administrative Intern
Team Formation
Strategize
C. difficile Infection Prevention Bundle
• Hand hygiene (washing with soap and water for C. difficile)
• Contact precautions
• Sign placement
• PPE readily available / used
• Dedicated rectal thermometers
• Patient placement
• private room vs. cohorting
• Bathrooms
• dedicated or commode
• Transport precautions
• Environmental cleaning
• hypochlorite-based disinfectant
• daily and terminal cleaning procedures
Hand Hygiene
n = 7,224
99
98
97
96
95
Percentage 94
93
92
91
90
89
2010
2011
2012
Petrie
Brooklyn
Lapses in Hand Hygiene
• Moment 4 = 67%
• Patient Care Services = 70%
Contact Precautions Traffic Light
PATIENTS ON ISOLATION PRECAUTIONS
March 7, 2013
Patient
MR#
Room
Source
Organism
Precautions
F
6
5L02A
Blood
MDR Acinetobacter / VRE
Strict Contact
G
7
5L03A
Urine / Wound
MDR Klebsiella / VRE
Strict Contact
H
8
5L03B
Blood
MDR Acinetobacter / VRE
Strict Contact
I
9
5L03C
Blood / Nasal
MDR Klebsiella / MRSA
Strict Contact
J
10
5L04C
Wound
MDR Klebsiella / MDR Pseudomonas / VRE/ MDR
Acinetobacter
Strict Contact
M
13
SICU10
Blood / Wound
MRSA
Contact
N
14
SICU01
Abscess
VRE
Contact
O
15
11L16P
Wound
MRSA / C. difficile
Contact
P
16
11L12B
Stool
MRSA
Contact
U
21
5L01B
Nasal
MRSA
Contact
V
22
5L02B
Sputum
MRSA
Contact
W
23
MICU07
C. difficile
Contact
X
24
11L12B
C. difficile
Contact
Y
25
10D05S
C. difficile
Contact
Contact Precautions Traffic Light
Patients with Multi-Drug Resistant (MDR) or Pan-Drug Resistant (PDR)
Acinetobacter, Klebsiella, etc. should be on strict contact precautions and
cohorted. Staff caring for these patients should not care for other non-infected
patients. Equipment used on these patients should not be used on non-infected
patients.
Care givers should wear gowns and gloves when entering the room to
see these patients. Masks should be worn if suctioning is necessary.
Rooms must be terminally cleaned after a patient with this organism is
discharged and cleared by Infection Control before a new patient is
admitted.
Patients with Clostridium difficile should be cohorted. Upon discharge,
the room must be terminally cleaned using a 1:10 bleach solution
after initial cleaning with the hospital approved germicide. While a
patient is in the hospital a 1:10 bleach solution should be used for
daily cleaning as needed.
Contact Precautions
CDI Bundle Compliance
Ownership by the Unit
CDI Infection Prevention
Bundle Compliance
100
90
80
70
Compliance
60
Rate %
50
40
30
20
Petrie
KHD
Time
Bundle Compliance
Don’t Work Against Each Other
Environmental Cleaning
• The key to cleaning and disinfecting
environmental surfaces is the use of friction
(“elbow grease”) to physically remove
visible dirt, material and debris which can
contain microorganisms.
• If this material is not removed
disinfectants will not be effective.
then
Environmental Cleaning
Environmental Cleaning
Ownership by the Department
Environmental Cleaning
Ownership by the Department
Environmental Cleaning
Ownership by the Department
Environmental Cleaning
Ownership by the Department
Environmental Cleaning
Ownership by the Department
Cleaning
Compliance Rate
90
80
70
60
50
40
30
20
10
0
EVS
IC
2011
2012H1
2012H2
2013Q1
Monitor CDI
HO CDI
BI Petrie
Year
Number of Patient days
Number of CDiff
Rate (95% CI)
Sept-Dec/2009
104,762
129
12.3 (10.3-14.6)
2010
223,675
193
8.6 (7.5- 9.9)
2011
231,123
170
7.4 (6.3- 8.5)
2012
229,709
140
6.1 (5.1- 7.2)
HO CDI
BI Brooklyn
Year
Number of Patient days
Number of CDiff
Rate (95% CI)
Sept-Dec/2009
35,390
58
16.4 (12.4-21.2)
2010
69,879
105
15.0 (12.3-18.2)
2011
71,392
108
15.1 (12.4-18.3)
2012
68,914
91
13.2 (10.6-16.2)
Value Analysis
On the CUSP Calculator
• CDI Cases
• Increased Length of Stay
• Mortality
• Median Excess Costs
• Savings Based on Percent Reduction
• Range $329,640 - $849,756
HO CDI
• Root Cause Analyses
•
•
•
•
•
•
Handling of soiled linen
Environmental cleaning
Use of laxatives
Delays in obtaining specimen
Use of nexium
Use of fluroquinolones
Pharmaceutical Stewardship
Pharmaceutical Stewardship
Clinical Infectious Diseases
Sept 1, 2012 Volume 55 page 615
HO CDI
28% decrease!
HO CDI
5% decrease
Success
• Measuring and Assessing
Effectiveness
•
•
•
•
•
Timely
Understandable
Multiple disciplines
Celebrate
Assure continued
improvement
• Sustainability