Building on Patient Safety

Clostridium difficile practice opportunitiesMary Ellen Scales RN MSN CIC

Baystate Medical Center

Objectives

At the conclusion of this session the participant will be able to :Plan Clostridium difficile infection prevention

strategies for their healthcare setting

Clostridium difficile practice opportunities Prevention strategies:

1. Identifying patients suspect or confirmed with CDI2. Preventing transmission3. Preventing recurrence

Included in this presentation: Survey results, references, resources and opportunities to influence your practice

1. Identification of PatientsWhat are the main clinical symptoms

of C. difficile-associated disease?Clinical signs/symptoms include:watery diarrhea fever loss of appetite nausea abdominal pain/tenderness

http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#6

Definition of diarrhea

http://www.thefreedictionary.com/diarrheaExcessive and frequent evacuation of watery

feces Diarrhea is defined by the World Health

Organization as having 3 or more loose or liquid stools per day (or as having more stools than is normal for that person).

Bristol Stool Chart

Reproduced by kind permission of Dr KW Heaton, Reader in Medicine at the

University of Bristol

Date Time Colour Type No Blood Mucus Amount Comments Initials

1. Identification of PatientsPatients who are at increased risk

for C. difficile-associated disease, Risk Factors:antibiotic exposure gastrointestinal surgery/manipulation long length of stay in healthcare settings a serious underlying illness immunocompromising conditions advanced age

http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#6

1. Identification of Patients Microbiological testing

Stool culture for C. difficileThis is the most sensitive test available, but the one most often

associated with false-positive results due to presence of non-toxigenic strains.

Antigen detection for C. difficile These are rapid tests (<1 hr) that detect the presence of C. difficile

antigen. They must be combined with toxin testing to verify diagnosis.

Toxin testing for C. difficile Enzyme immunoassay detects toxin A, toxin B, or both A and BTissue culture cytotoxicity assay detects toxin B only.

* C. difficile toxin is very unstable. The toxin degrades at room temperature and may be undetectable within 2 hours after collection of a stool specimen. False-negative results occur when specimens are not promptly tested or kept refrigerated until testing can be done.

http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#6

Low magnification micrograph of colonic pseudomembranes in Clostridium difficile colitis, less precisely also known as pseudomembraneous colitis.

The presence of pseudomembranes is not synonymous with Clostridium difficile colitis; pseudomembranes may arise due to other infectious organisms and/or bowel ischemia

http://en.wikipedia.org/wiki/File:Colonic_pseudomembranes_low_mag.jpg

Additional criteria for Clostridium difficile: Pseudomembranous colitis is seen during endoscopic examination or surgery; andPseudomembranous colitis is seen during histopathological examination.MacDonald,L.C, et al ICHE February 2007,

VOL. 28, NO. 2

Pseudomembraneous colitis

Microbiological testing

Survey results: check all that apply

20. Does the laboratory in your facility have a rejection policy for stools specimens?

Answer Options Response Percent Response Count

No 45.8% 11 Yes, for formed stools 25.0% 6 Yes, duplicate stools within an admission 4.2% 1 Yes, duplicate stools within an illness 0.0% 0 Yes, Other (please specify) 29.2% 7

answered question 24

Microbiological testing

Survey results: 24 respondents

19.How frequently does the lab perform C. difficile testing?

Answer Options Response Percent

Response Count

Daily 66.7% 16 5 days / week 8.3% 2 3 days / week 0.0% 0 Other (please specify) 25.0% 6

answered question 24

Microbiological testing

Survey results: if yes, check all that apply21. Does your facility currently have a system that rapidly (within 24 hours following laboratory identification) notifies staff of new patients with CDI?

Answer Options Response Percent Response Count

No 8.3% 2 Yes, Infection control is notified 70.8% 17 Yes, Patient care unit is notified 79.2% 19 Yes, other is notified (please specify) 25.0% 6

Surveillance: develop a case definition for your institution or follow established surveillance criteria

Patient criteriaSigns and symptomsAdmission/Discharge/ Transfer dataMicrobiological testing

Prior history of CDI Time frames regarding health care

episodes for relevancy

Practice opportunities Signs and Symptoms:

Bristol Stool chart Laboratory testing:

Microbiological and Histopathological testing guidelines for your institution

Surveillance definitionsNHSN module NHSN/CDC*Facility designed algorithm

( see BMC example in handouts) * McDonald, L.C. et al. Recommendations for Surveillance of Clostridium difficile- Associated Disease. Infection Control and Hospital Epidemiology; Feb 2007, Vol.28, No.2.

2. Prevent transmission

Hand Hygiene Patient Placement Transmission prevention Cleaning and disinfection of equipment

and environment

Hand HygieneAPIC1 : Perform hand hygiene

upon removal of gown and gloves and exiting the patient’s room

Use alcohol hand rubs for hand hygiene during routine infection prevention and control responses to C. difficile

Hand washing is the preferred method when hands are visibly soiled

Assess hand hygiene compliance to address obstacles to performance

Patient /Visitor Education

IDSA2: In outbreak or increased

CDI rate, instruct visitors and healthcare workers to wash hands with antimicrobial soap and water after caring for or contacting patients with CDI

1. APIC Guide to the Elimination of Clostridium difficile in Healthcare settings 2008

2. SHEA-IDSA Cohen, S. H. et al, Guideline Infection Control land Hospital Epidemiology May 2010 Vol 31, No. 5

For CDI patients, what is the preferred method of hand hygiene used in your facility?

83%

4%13%

Soap and water

Alcohol hand gel

Both available butneither preferred

Other (please specify)

Patient PlacementAPIC1 : Place patients with CDI on

Contact precautions in private rooms when available. Preference for private rooms should be given to patients with fecal incontinence.

If a private room is not available, cohort patients with CDI, however not with patients with other organisms of significance (MRSA,VRE, Acinetobacter)

Put on a gown and gloves to enter the patient’s room

IDSA2: Patients with CDI to be placed

in a private room on contact precautions. If single room is not available, cohort patients, providing a dedicated commode for each patient. Maintain contact precautions for the duration of diarrhea.

Healthcare workers and visitors must use gloves and gowns on entry to a room of a patients with CDI.

1. APIC Guide to the Elimination of Clostridium difficile in Healthcare settings 2008

2. SHEA-IDSA Cohen, S. H. et al, Guideline Infection Control land Hospital Epidemiology May 2010 Vol 31, No. 5

How frequently are patients with CDI in your facility placed on Contact Precautions?

92.0%

8.0%

AlwaysOftenSometimesRarelyNever

How long are patients with CDI kept on Contact Precautions?

25%

42%

13%

21%

A. For duration of diarrhea

B. For duration ofhospitalization – untildischargeC. Until a specified number ofstools test negative

D. For a specified time periodafter diarrhea resolves

In your facility, how frequently are patients with CDI placed in private rooms?

71%

17%

4%

4%

4%

Always

Often

Sometimes

Rarely

Never/no privaterooms available

If your facility does not have a sufficient number of private rooms available, what does your facility do with patients who are

identified with CDI? (please check all that apply)

Cohort with other CDI patients, 67%

Place with other patients but use separate

commodes/bathrooms, 33%

Place with other patients sharing bathrooms, 0%

Not Applicable (a sufficient number of private rooms are available), 29%

Other (please specify), 17%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Example of isolation rounds tool in packet

How many patients in each category and opportunity add categories

How many patients with barrier supplies missing

Patient details

APIC1 : Use dedicated equipment

(blood pressure cuff, thermometer, stethoscope)

Use EPA –approved germicide for routine disinfection during non-outbreak situations

Ensure personnel allow appropriate contact time and are appropriately trained.

Address specific items in daily cleaning in patient’s room

Disinfect all shared items between patients

Monitor adherence to cleaning and disinfection processes

IDSA2: Identify and remove all

potential environmental sources of C. difficile, including rectal thermometers, replace with disposables.

With increased rates of CDI, use chlorine containing cleaning agents or other sporicidal agents to address environmental contamination.

Routine environmental screening for C difficile is not recommended

1. APIC Guide to the Elimination of Clostridium difficile in Healthcare settings 2008

2. SHEA-IDSA Cohen, S. H. et al, Guideline Infection Control land Hospital Epidemiology May 2010 Vol 31, No. 5

Cleaning and Disinfection of Equipment and the Environment

Is a bleach-product used for environmental disinfection for CDI patients at your facility?

No, 29%

Yes, 71%

When is a bleach-product used for environmental disinfection for CDI patients at your facility?

(check all that apply)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

For terminal cleaning For daily cleaning Other (please specify)

Do you directly evaluate environmental cleaning and disinfection practice?

No, 46%

Yes, 54%

Who conducts observations of environmental cleaning and disinfection?

(please check all that apply)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

InfectionPreventionist

Environmentalservices

Unit staff Other (pleasespecify)

Does your facility use dedicated noncritical medical items (such as blood pressure cuffs or stethoscopes) for patients

with CDI?

Yes, 75%

No, 25%

Practice opportunities Hand hygiene

Soap and water AHR

Patient placement Precautions Cohorting Barrier attire availability

Cleaning and Disinfection of Equipment and Environment Practice Products Process

3. Prevent recurrence

Antimicrobial stewardship Home Care

APIC1 : Implement a program that supports the judicious use of antimicrobial agents Program should incorporate a process that monitors and evaluates antimicrobial use and provides feedback to medical staff and facility

leadership

IDSA2: Minimize the frequency and duration of antimicrobial therapy

and number of antimicrobial agents prescribed to reduce CDI risk

Implement an antimicrobial stewardship program . Antimicrobials should be based on the local epidemiology and C difficle strains present, but restricting the use of cephalosporin and clindamycin ( except for surgical prophylaxis) may be particularly useful.

1. APIC Guide to the Elimination of Clostridium difficile in Healthcare settings 2008

2. SHEA-IDSA Cohen, S. H. et al, Guideline Infection Control land Hospital Epidemiology May 2010 Vol 31, No. 5

Antimicrobial Stewardship

Does your facility have a specific person (or people) responsible for reviewing antibiotic utilization

with the goal of promoting the judicious use of antimicrobial agents?

No, 30%

Yes, 70%

Practice opportunities for the team

Antimicrobial stewardship programAntimicrobial ordering, restriction, monitoring

Home careEducation HygieneBarrier attire

Objectives

At the conclusion of this session the participant will be able to :Plan Clostridium difficile infection prevention

strategies for their healthcare setting