Organization Frederick Memorial Hospital Solution Title Optimizing Care: An Integrated Collaboration to Reducing C-Diff

Program/Project Description, including Goals:

The goal of any new program is to optimize it to its greatest value. Often this can prove difficult due to many factors, including the silo approach to treating patients and addressing performance improvement issues within departments. FMH was experiencing a higher than acceptable hospital-acquired infection rate and numerous patients that were being readmitted multiple times for treatment of C.difficile infections (CDIs), at times requiring prolonged hospitalization and surgery due to complications of the C.difficile infections. At times, this may have contributed to the patients’ ultimate demise. As an organization, we evaluate all possible actions that can be taken to improve the outcomes for our patients. As with other quality improvement and patient safety initiatives, we learned the value of having a bundled approach to improvement. Solving the problem of C.difficile infections likewise required an increased awareness and an integrated bundled approach to be effective. The goal of this initiative was to decrease the hospital acquired C.difficile infections, and to appropriately identify and treat those with community acquired CDIs, which is higher than the national average. This was accomplished by applying best practices, such as rapid identification of cases, control of antibiotic use, proper approaches to room and equipment cleaning and disinfecting and following the best infection control practices. This initiative included the development of an Enteric Protocol Team that met and rounded on a routine basis to review the care and identify any actions that could be taken to improve patient outcomes. This team was comprised of individuals from performance improvement, case management, infection control, pharmacy, environmental services, nutrition, clinical specialists, nursing, patient/family and physician representation from the Infectious Disease physician, GI physicians and general surgeons.

Learning Objectives

1. Participants will be able to appropriately identify patients with a C. difficile infection (CDI)

2. Participants will be able to implement appropriate early treatment protocols 3. Participants will be able to list common obstacles to infection prevention and strategies to

overcome them 4. Participants will be able to identify and implement preventive measures to reduce the

occurrence of hospital acquired CDIs and to prevent the spread of community acquired CDIs

Process: Various strategies in the past have proven ineffective in decreasing the rates of hospital acquired C. difficile. As an organization, we needed to evaluate all possible actions that could be taken to improve our patient’ outcomes. After observing the processes, it was apparent that we needed to make changes to the cleaning/disinfection and specimen collection, isolation practices, medication management and appropriate documentation to ensure proper procedures are being followed. As with other quality and patient safety initiatives, we learned the value of the bundled approach and inter-department collaboration to achieve improvement. Solution: Numerous processes have been implemented to ensure the success of this initiative, including the implementation of rounding by the Enteric Protocol Team, including a nursing checklist, developed and enhanced education materials for staff, physicians and patient/families to raise awareness, discharge instructions tailored to discharge locations, instituted an antimicrobial stewardship program, and environmental cleaning protocols. The rounding approach allows for rapid improvement to patient care to improve outcomes. Measurable Outcomes: We achieved an integrated approach to addressing the treatment of patients with a C.difficile infection, as well as strategies for prevention. The department silos have been overcome to allow this integrated Enteric Protocol Team to effectively manage patient safety and the environment in which the patient is cared. While initially the number of patients identified with CDIs increase due to raised awareness and improved specificity of testing, once the protocols were in place to ensure appropriate treatment the complications from and occurrences of hospital acquired CDIs declined.

Sustainability: What measures are being taken to ensure that results can be sustained and spread?

Continual monitoring and data analysis allows for quick analysis of any identified issues or breaks in protocol.

Role of Collaboration and Leadership: The key players included the infection control practitioners, the infectious Disease physician, performance improvement department, GI physician, surgery department, pharmacy, case management, environmental services and nursing. Healthcare providers across the spectrum had to be aware of and understand the impact of C.difficile infections for patients and the caregivers. This meant breaking down the silo mindset of how patients are treated. The departments involved had to “buy-in” to the importance of this initiative to dedicate the resources and ensure participation on the Enteric Protocol Team. Administrative and physician leadership support was critical in the success of this initiative. Innovation: What makes this Solution innovative? What are its unique attributes? This initiative is innovative because it included the development of an Enteric Protocol Team that met and rounded on a routine basis on every admitted patient with C-Diff to review the care and identify any actions that could be taken to improve patient outcomes. This team is

comprised of individuals from performance improvement, case management, infection control, pharmacy, environmental services, clinical specialists, nursing, patient/family and physician representation from the Infectious Disease physician. In addition, the Administrator on-call rounds with the team one day each week. As with other quality improvement and patient safety initiatives, we learned the value of having a bundled approach to improvement. Solving the problem of C. Difficile infections likewise required an increased awareness and an integrated bundled approach to be effective.

Related Tools and Resources Contact Person Sharon Powell, MS, RN, CPHQ Title Patient Safety Officer & Director, Performance Improvement, Accreditation & Regulatory Compliance, Infection Prevention & Control, Medical Staff Office, & Interpreter Services Email spowell@fmh.org Phone 240-566-3514 The Solutions selected to receive the Minogue Award for Patient Safety Innovation will reflect the following Award criteria: • Be innovative • Demonstrate measurable change • Exhibit strong collaboration • Exhibit strong leadership • Advance the culture of patient safety • Constitute a best practice with the ability to spread

IPAC 11/2012

ISOLATION PRECAUTIONS FOR DIARRHEA

Best Practice to be applied under the following clinical circumstances:

YES

NO YES NO YES NOTE

• If stool sample is positive – repeat stool testing is not needed. If stool sample is negative but patient continues to have diarrhea, repeat testing in seven days may be considered.

• Repeat C. diff testing is not necessary to determine duration of treatment or to discontinue Enteric Precautions. • Negative C. diff test is not required for discharge to NH/LTC. • Other diarrhea-causing organisms can be transmitted by the fecal oral route. • Other things that can result in diarrhea include recent bowel surgery, chemotherapy, radiation therapy, tube feeding,

Does the patient have diarrhea? • Diarrhea: New onset of observed diarrhea (e.g.≥3 loose/watery bowel

movements in a 24 hour period) that is unusual or different for the patient, and not caused by laxatives or bowel prep.

• Loose/watery bowel movement: if the stool were to be poured into a container, it would conform to the shape of the container.

Place Patient in Enteric Precautions

Ask: Is the patient on: Miralax, colace, senekot, bowel prep, CT contrast, or lactulose?

• Do not send stool for C. diff assay!

• Contact IPAC for removal of Isolation once diarrhea ends.

• Continue Enteric Precautions AND inform physician of symptoms and diarrhea.

• Send freshly collected (<1hr) stool for: C. diff toxin assay (Send liquid stool only. The lab will not test formed stool).

Positive toxin assay Negative toxin assay

Notify MD of positive results. Continue ENTERIC Isolation until discharge.

Does the patient have a recent (< 8 weeks) positive history of C. diff and does the

patient have Diarrhea (3+ loose stools)?

Discuss with IPAC before discontinuing isolation*

General Discharge Instructions for the LTC Clostridium difficile patient

• Please note that your patient has/ is C. difficile positive.

• Please follow the discharging physician’s treatment plan for C. diff.

• It is not necessary to test the patient for C. diff again during or after treatment.

• Avoid additional or new antibiotics as much as possible.

• Discuss with your pharmacist and doctor(s) about using narrower spectrum antibiotics.

• The FDA has released a warning about the association between proton-pump inhibitor drugs (PPIs, e.g. Nexium, Protonix, Prevacid, Prilosec, Aciphex, Zegerid, Dexilant, and Vimovo) and C. diff diarrhea.

o Patient should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.

• Continue probiotics (yogurt, lactobacillus, acidophilus) during and post C. diff treatment.

• Please assist your patients with hand-washing with soap and water, especially after using the bathroom and before meals.

• Good infection control practices to use in nursing home include frequent handwashing with soap and water for staff, patients, visitors, and family.

• We recommend that patients shower at least every other day (daily is preferred).

• Consider placing patient in private room if possible.

• It is recommended that rooms of C. diff patients be cleaned daily with bleach product, with

special attention paid to high-touch items.

• It is known that the frequency of C. diff acquisition is linked to level of environmental contamination. Consider auditing the quality of room-cleaning in your facility.

C. DIFF IS NOT AN INEVITABLE PART OF MODERN HEALTHCARE. IT IS AN AVOIDABLE EVENT!!!

WE CANNOT DO IT ALONE. IT TAKES A VILLAGE TO MAKE A DIFFERENCE!

For questions, call the Infection Control and Prevention Team at Frederick

Memorial Hospital (240-566-3519; 240-566-3509).

General C. diff Home Discharge Instructions

• Please follow your discharge physician’s treatment plan for diarrhea.

• Do NOT stop your medication without discussion with your Doctor.

• Notify other Care Providers about your recent diagnosis of C. diff.

• Avoid taking additional antibiotics for the next few months if possible.

• Have a good discussion with your Health Care Provider to see if antibiotics are really needed.

• Wash your hands frequently with soap and water, especially before eating and after

toilet use.

• Continue taking Probiotics every day (e.g. cultured yogurt, Lactobacillus, Acidophilus) for some time after finishing your C. diff treatment.

• Take a good shower every day to get rid of C. diff. Pay attention to your hands, nail beds,

groin, abdomen, buttocks, chest, and arms.

• Have your tub, toilet seat, toilet, toilet handle, sink, faucet handle, and counter top all cleaned daily with 10% household bleach. This can be done by mixing 1 part of bleach with 9 parts of water. Make fresh bleach each time for cleaning. Wear gloves while cleaning, and wash your hands again with soap and water after cleaning is complete.

• If you are taking medicines for acid control or GERD call PPI’s, such as Nexium,

Protonix, Prevacid, Prilosec, Aciphex, Zegerid, Dexilant, and Vimovo—talk to your Health Care Provider, as these medications increase the risk of C. diff. (A lowest dose and shortest duration of therapy is suggested.)

• Wash your soiled laundry with detergent in the hottest water cycle. Some bleach will

help kill the C. diff germs. Dry the items in the dryer.

• Wear disposable diapers if incontinence is an issue, to reduce the risk of contamination of your surroundings.

• It is preferred that you have your own private bathroom and shower.

• Standing showers are recommended as opposed to tub baths.

C. DIFF IS AVOIDABLE!!! Protect yourself from a relapse of infection and prevent spread

to your family or friends. This hardy bacteria is only killed by 10% household bleach.

Prepared by the Infection Control and Prevention Team at Frederick Memorial Hospital