Saint Thomas Midtown Hospital

Journey for Elimination of

Clostridium difficile

Clostridium difficile Infection (CDI)

• One of most common Healthcare associated infections (HAIs)

• Affects almost 1% of hospitalized patients each year

• Since 2000, the incidence of CDI has increased more than 200%

– other HAIs have decreased

• >300,000 hospitalizations involve a CDI each year

• Annual cost up to $4.9 billion to the US healthcare system

Healthcare Associated Infections

High Reliability Organization Workgroup

(HAI HROw)

• Recommending and approval body - May 2014

– Multidisciplinary system team

– Reviews metrics/data

– Recommendations/action items

• Developed system policy – March 2015

– Approvals or denials

Basics

• Hand Hygiene – Handwashing

• Isolation

– Utilize ante room for isolation

– Gown and gloves before entering isolation room

• Visitors > same precautions

– Isolate for duration of hospitalization

• Infection Prevention may assess long term patients

• Root Cause Analysis (RCA)

– Conduct RCA with each event

• Huddle on unit, present case, identify gaps/ opportunities, develop action plan, provide education

– Participants – nursing, pharmacy, ES, ID, IP

Environmental Decontamination • Bleach

– Daily

• Focus on high touch surfaces

– Terminal clean

• Discharge or transfer

• Adenosine TriPhosphate (ATP) Testing

– Detects organic matter; presence indicates the surface is not clean

– Test select surfaces of isolation rooms after terminal clean

• Rotate surfaces tested periodically

– Requirement to pass before release of room for new patient

• Passing Score for a patient room <50

• Failure > required to reclean and retest

ATP Testing Results

Category/Item Number of

Times Tested

Feb 18'

score

Scoring

Threshold

Variance Course of Action Taken

Bathroom hand rails by toilet 3 100% 95% 5%

Bathroom inner door knob/plate 2 100% 95% 5%

Bathroom light switch 5 100% 95% 5%

Bathroom sink 9 100% 100% 0%

Bed rails/controls 26 88% 95% -7% Retrained the housekeeper

Bedside table/handles 4 75% 95% -20% Retrained the housekeeper

Call box/button 9 78% 92% -14% Retrained the housekeeper

IV pole (grab area) 2 100% 95% 5%

Chair 8 88% 92% -4% Retrained the housekeeper

Room inner door knob 7 100% 95% 5%

Room light switch 8 100% 95% 5%

Telephone 25 88% 95% -7% Retrained the housekeeper

Toilet flush handle 21 100% 95% 5%

Toilet seat 26 100% 92% 8%

Tray table 15 100% 92% 8%

Enter order “per protocol” for C diff Rapid Screen. This

order will trigger an automatic discontinuation order

for all laxatives. Collect the next liquid stool for

testing. Place patient on Contact Precautions while

awaiting results.

Stop laxative and gauge clinical

response prior to ordering C.

difficile testing.

YES

Has the patient been taking laxatives or

other medications that may cause

diarrhea1 over the past 24-48 hours?

YES

Observe for 24 hours for

persistence of diarrhea symptoms.

Do not order test for C. difficile.

Patient with clinically significant diarrhea (at

least 2 liquid stools within 24 hours) within

the 1st 3 days of hospitalization

NO

NO

Discontinue Contact

Precautions.

C. difficile results positive?

Nurse to notify the physician/allied health

personnel and begin treatment as ordered.

Keep patient on Contact Precautions. Do

not send follow-up C. difficile test (i.e. as a

test of cure).

Continue Contact Precautions until patient is

discharged. For prolonged hospitalizations, the

healthcare provider may contact the Infection

Prevention Department for exemption on a case

by case basis.

YES

NO

Nurse Driven Algorithm ORDER C. DIFFICILE TEST WITHIN 1ST 3 DAYS OF HOSPITALIZATION (Oct 2014)

Clostridium difficile Order – Criteria for Use

February 2017

• Created due to high sensitivity of C difficile PCR lab test

• Important to decrease the rate of false positives by only

testing patients with clinically significant diarrhea at risk for

infection

• Tests of cure are discouraged

• Criteria for Use recommended before ordering a C difficile

test

Power Form for

Ordering C difficile

Clostridium Difficile Order – Criteria for use

I acknowledge that all of the following criteria should be met prior to ordering a C. Diff lab test

Clinically significant diarrhea (defined as at least 2 liquid stools within 24 hrs)

The Specimen must be liquid stool. Formed stool will not be tested.

No laxatives have been administered in the last 24-48 hours.

Patient has NOT had a negative C. Diff test in the past 7 days (tests should not be repeated within 7 days of a negative test unless the clinical scenario has changed)

Patient has not had a positive C. Diff test in the past 30 days (no “test-of-cure” recommended)

Previous Laxative Orders Bisacodyl 10mg sup….11/4/15 Miralax 17 gm packet…11/6/15

Previous C. Diff test results xyz(+)….….11/5/15 abc (-) ….…11/6/15

Clostridium difficile Kit Usage

348

415

491

473

451

410

469 476 479

456

352

426

481

418

388 389

359

322

355

329 338

348 333

357

334

281

0

100

200

300

400

500

600

Jan16

Feb16

Mar16

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

# o

f C

.Diff

Kit T

ests

C. difficile Criteria for Use

Implemented February 2017

Antimicrobial Stewardship

• The most important modifiable risk factor for the

development of CDI is exposure to antimicrobial agents.

The Antimicrobial Stewardship Program (ASP) has been

developed to assist in appropriate antibiotic use.

• Program began in February 2013

Fluoroquinolone Recommendations

August 2017

• Developed the Levaquin Criteria for Use requiring

documentation of criteria using a PowerForm in the EMR at

time of ordering

• Pharmacist conducts a prospective review of

fluoroquinolone orders daily using Sentri7 and assesses the

appropriateness of selected indications.

– Inappropriate utilization is discussed with the attending

physician for an alternative antibiotic

25.1 25.5 25.5

24.4

20.3

13.9

19.8

13.1

12 11.1 9.2 8.7

41

26.9

34.7

26.5

17

16.1

20.46

12.3

12.6

6.4 7.5

5.1

0

5

10

15

20

25

30

35

40

45

March-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

STM Antibiotic Dashboard DDD/1000 Patient Days

Cipro

Levo

DDD = Defined Daily Doses

Revision of Testing for Clostridium difficile

May 2017

• Molecular tests were used to diagnose C difficile infection

(CDI), but many molecular test-positive results lack toxins

that historically defined disease

– Unclear need for treatment > detection of colonization

• CDI diagnosis without test for toxins or host response is

likely to result in overdiagnosis, overtreatment and

increased healthcare costs

– Reference: Polage, Gyorke & Kennedy. (2015). Overdiagnosis of

Clostridium difficile Infection in the Molecular Test Era. Journal of

the American Medical Association. Retrieved from doi:10.1001/

jamainternmed.2015.4114

Clostridium difficile Testing Change

• PCR test will be made available upon request by MD after Cdiff Rapid Screen test is complete.

MD must call lab to order test.

Rapid Screen Result Reported in Cerner as

Toxin-/GDH- Negative for C. difficile antigen and toxin

Toxin-/GDH+ Toxin Negative. See comment Add comment: “C. difficile toxin negative but GDH antigen positive. This most likely represents bacterial colonization and does not warrant treatment. A careful evaluation of symptoms should be completed and other causes of diarrhea ruled out. C. difficile isolation is indicated while the patient has active diarrhea.”

Toxin+/GDH- Retest using a fresh specimen required. (Directions for Lab: If sample retests with the same result, report as Toxin positive)

Toxin+/GDH+ Positive for C. difficile antigen and toxin

Change in C. difficile test,

May 2017

Challenges/Opportunities

• Obtaining specimens at the proper time

• Laxatives given and testing for C difficile

• Compliance to policy

• Healthcare cycles

• Antibiotic therapy for other bacterial infections during

C difficile treatment

• Correlation with other factors, i.e., PPI, acid suppression therapy, antibiotics

• NAP detection unable to identify with new testing methodology

• Use of new technology – Ultraviolent Radiation

• Future use of Standardized Antimicrobial Administration Ratio (SAAR) to monitor antibiotic trends

Questions??