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

New England Baptist Hospital, Boston, MA

Presentation 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

New England Baptist HospitalJune 2008

Received the CDI Surveillance Working Group CDI definitions at the APIC Conference 2008 in Denver

ICP 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 Contributing Factors:

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, 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

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%)

Enhanced Prevention 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 (testing done by VAMC, W. Palm Beach, FL – biological indicators (G. stearothermophilus) placed around the room in areas to being treated – all were negative)

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

NEBH CDI Rates FY08-FY10 FY08 FY09 FY10 (Oct-Apr)Total HAI 21 Total HAI 13 Total HAI 7

Patient Days 28914 Patient Days 28382 Patient Days 15967Rate/10,000PtDays 7.3

Rate/10,000PtDays 4.6

Rate/10,000PtDays 4.4

      (37% reduction)    

Hospital Onset 13 Hospital Onset 10 Hospital Onset 5Rate/10,000PtDays 4.5

Rate/10,000PtDays 3.5

Rate/10,000PtDays 3.1

      (22% reduction)    

Comm Onset HA 8Comm Onset HA 3 Comm Onset HA 2

Rate/10,000PtDays 2.8

Rate/10,000PtDays 1.1 Rate/PtDays 1.2

(61% reduction)

Interventions in 2010 Decontamination of the Ambulatory

Care Unit (our “mini-ER”) after observing commode handling procedures and use of community bathroom by CDI patients.

Decontamination will be done in July on the night shift with a vaporized hydrogen peroxide room decontaminator.

Implemented commode liners to eliminate disposal of liquid waste by staff.

Healthcare Facility Acute Care Hospital

Rehabilitation Facility Nursing Home

Other Chronic Care

A case of C. difficile is defined as a case with diarrhea without other known etiology. The stool sample will yield a positive result for laboratory assay for C. difficile toxin A and/or B (or positive PCR) 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)

Example of a Run Chart

Presentation 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