Maureen Spencer, RN, M.Ed., CICInfection Control Manager

New England Baptist Hospital, Boston, MA

Objectives

Demonstrate how one hospital used the new CDI surveillance definitions to identify an increase of CDI on one nursing unit.

Describe enhanced environmental controls to reduce transmission of CDI

Describe the new Clostridium difficile Infection (CDI) Collaborative Definition

June 2008

Received the CDI Surveillance Working Group CDI definitions at the APIC Conference

Presented the new surveillance definitions to the Infection Control Committee

Reclassified cases in July 2008 Identified one nursing unit with 76% of the

cases of HA-CDI Several of the patients had also been in the

ICU and were transferred in an ICU bed rather than stretcher, and often went back and forth between the two units in the same bed

Patients were being removed from Special Contact Precautions after diarrhea stopped, prior to discharge – housekeeping didn’t know the room needed to be cleaned with bleach or cubicle curtains changed

New Surveillance Definitions

Initial Investigation August 2008 •FY08 = 24 Patients with positive C.difficile

titers – 3 from outpatient locations –21 from inpatients (87.5%) 

•Nursing Unit - Developed Signs and Symptoms: –J4 East 16/21 cases (76%) –L 5 1/21 cases ( 5%) –5 East 3/21 cases (14%) –ICU 1/21 cases ( 5%) 

3 of 16 Jenks4East cases were in room 465

- 2 of the CA-CDI (community-acquired) cases were in room 465 

Poster we presented at APIC 2007 showing CDI with room association – 28 patients had been in 42 rooms!

Month Hosp Onset

Community Onset – HAI

Indeterminate Community-acquired

Total

October 1 2 1 1 5

November 3 1 3 7

December 1 2 0 3

January 1 0 1

February 2 2

March 1 1 1 3

April 0

May 0

June 1 1 2

July 2 2

Aug 1 2 1 4

Sep 2 3 5

Total 13 8 3 10 34

FY2008 - NEBH Cases Per New Definitions

C.Difficile Team - August 08

Formation of C.Difficile Team: Dr. Camer (Chief of Surgery) Dr.

Lui (Chief of Gastroenterology), Sharon Connolly, RN – Nurse Manager, Sue Cohen,MT (ASCP) Microbiology Supervisor, Pam Dejoie, Maureen Spencer, RN, Infection Control

Met weekly, reviewed literature, formulated control measures, designed a retrospective case review, and educational offerings

Instituted Use of Chlorox Bleach Wipes

Enhanced Education for Staff Changed patient transfer

procedure Stretcher (not in bed)

Retrospective Case Review of all CDI cases

Enhanced Education

Transfers between units on stretchers versus contaminated bed Green tag flagging system for cleaned

equipment

Dinamap baskets with sanicloths and not allowed in precautions rooms

Spatial Separation of precaution cases Bleach wipes for all precaution rooms Enhanced cleaning of equipment

Nursing Unit Decontamination Decontaminated 19 rooms with dri-mist particle

generator that breaks down disinfectant into microscopic, negatively charged ion particulates.

These particulates are smaller than one micron in diameter and can access ALL surfaces of a room.

Particulates are negatively charged and stick to positively charged contaminants

Some evidence it will kill spores

Three day period – lease arrangement with company

Cost: ~$5000.00 for 19 rooms Issues: set off smoke detectors, prep time to seal

ventilation and doors

FY08

Total HAI 21

Patient Days 28914

Rate/10,000 PtDays 7.3

   

Hospital Onset 13

Rate/10,000 PtDays 4.5

   

Comm Onset - HA 8

Rate/10,000 PtDays 2.8

Comparison of Rates 2008-2009

FY09

Total HAI 13

Patient Days 28382

Rate/10,000 PtDays 4.6

   

Hospital Onset 10

Rate/10,000 PtDays 3.5

   

Comm Onset - HA 3

Rate/10,000 PtDays 1.1

Retrospective Case ReviewFY2008 N=34

Proton pump inhibitors 13 (67%) Cancer 12 (35%) Fluorquinolone use 9 (26%) Obesity 9 (26%) CT Scan before onset 6 (18%) MRSA Colonization 5 (15%) VRE Colonization 3 ( 9%) Diabetes 3 ( 9%)

Healthcare Facility Acute Care Hospital

Rehabilitation Facility Nursing Home

Other Chronic Care

A case of C. difficile is defined as a case with the symptom of diarrhea without other known etiology. The stool sample will yield a positive result for laboratory assay for C. difficile toxin A and/or B. For purposes of this collaborative, C. difficile is limited to laboratory confirmed cases. This collaborative will track healthcare facility associated C. difficile

C. difficile (CDI) Collaborative Definition

C. difficile (CDI) Collaborative Definition

A patient classified as having a case of healthcare facility associated C. difficile is defined as a patient who develops diarrhea more than 48 hours after admission

ORA patient classified as having any symptoms that develop within 48 hours after discharge to another healthcare facility.

ORA patient discharged to home with lab confirmed C.diffIcile within 28 days from the day of discharge and no intervening admissions. . (Day of discharge counts as day 0) Also counts if C.difficile is identified on readmission to your facility.

If the time of admission and/ or the time of diarrhea onset and/or the time stool was collected are not available, CDI can be considered to be healthcare facility onset if onset of diarrhea, with a positive stool occurs on or after the third calendar day after the day of admission (which is day zero).

EACH PATIENT ONLY COUNTS ONCE

Within 8 weeks of index diagnosis

C. difficile (CDI) Collaborative Definition

A patient readmitted after 8 weeks counts as a new patient /case

(E.g. Monday admit, day 4 = Thursday)

FACILITY HA-CDI RATE

# HA CDI cases / 10,000 Patient Days

(exclude NICU days)

Objectives

Demonstrate how one hospital used the new CDI surveillance definitions to identify an increase of CDI on one nursing unit.

Describe enhanced environmental controls to reduce transmission of CDI

Describe the new Clostridium difficile Infection (CDI) Collaborative Definition

THE END

THANK YOU