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Multidisciplinary Partnerships to Reduce Clostridium difficile Infection: A Success Story
Laura Johnson, MDHospital Epidemiologist, Infectious DiseasesHenry Ford Health System
Rachel Chambers, PharmDPharmacy Specialist, Antimicrobial StewardshipHenry Ford Hospital
Objectives
The burden and severity of Clostridium difficile infection (CDI) has dramatically increased in recent years
Multidisciplinary collaboration is key to minimizing CDI in the health care setting
This presentation will provide an overview of the key players and multidisciplinary interventions necessary to successfully manage and reduce CDI
Clostridium difficile Infection (CDI)
Bacterial infection of colon resulting in spectrum of disease from mild diarrhea to severe colitis with sepsis, toxic megacolon, and even death.
Spores persist in healthcare environment and are transmitted by fecal-oral route. Hands and Environment
Antibiotic exposure kills off normal protective gut flora and C. difficile can grow and produce toxins, resulting in disease.
Yearly Clostridium difficile–related Mortality by Listing on Death Certificates, United States, 1999–2004.
Redelings MD, et al. Emerg Infect Dis. 2007;13:1417-1419
De
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Increased and Severe CDI at HFH
2007/8: Patients noted to have severe CDI, some requiring colectomy 1988 to 2007: 8 colectomies March to May 2008: 7 colectomies
Surveillance of CDI Initiated
HFH Nosocomial C. diff Rates 2008-2009
0.0
10.0
20.0
30.0
40.0
Rat
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0,00
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Day
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Rate 22.6 14.8 21.5 31.3 24.7 19.3 14.7 17.3 16.8 17.2 26.3 24.0 23.3 21.7
Benchmark 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00
JAN FEB MA APR MA JUN JUL AU SEP OCT NO DEC JAN Feb
Investigation of Problem
Infection Prevention started surveillance program
Deep dive into severe CDI cases Collaboration of Infection Prevention, Pharmacy, Clinical
Quality and Safety Office, and Care Providers
Guidelines for C. difficile Prevention and Control
CDC Prevention Strategies: Core
Contact Precautions for duration of diarrhea Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and environment Laboratory-based alert system for immediate notification of
positive test results Educate about CDI: HCP, housekeeping, administration,
patients, families
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.htmlDubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.
CDC Prevention Strategies: Supplemental
Extend use of Contact Precautions beyond duration of diarrhea Presumptive isolation for symptomatic patients pending
confirmation of CDI Evaluate and optimize testing for CDI Implement soap and water for hand hygiene before exiting room of
a patient with CDI Implement universal glove use on units with high CDI rates Use sodium hypochlorite (bleach) – containing agents for
environmental cleaning Implement an antimicrobial stewardship program
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html
Implementing CDC Guidelines Requires a “SWOT” Team
Clear guidelines to prevent and control C. difficile
The challenge
Implementation Sustainability
C. difficile Task Force created To identify and address our “strengths, weakness, opportunities and
threats” To reach multiple disciplines in hospital and facilitate buy-in To change practice and culture related to prevention and control
practices
C. difficile Task Force
Infection prevention practitioners Providers: infectious disease, medicine, surgery, intensive care,
gastroenterology Nursing (general practice, intensive care, front line and educators) Pharmacy Laboratory Environmental services Facilities/plant operations Office of clinical quality and safety
Reporting to hospital leaders
Examples of Collaboration
Infection Prevention and Environmental Services Weekly rounds (with “bug meter”) Developed enhanced bleach cleaning protocols
Laboratory and Infection Prevention Improved turn around time for lab result Developed process for daily notification of results Enhanced lab testing with better sensitivity and specificity
Infection Prevention and ICU Nursing Team Developed protocol for RN-Initiated testing for CDI “Caboodles” for supplies to decrease contamination of supplies in room Eventually, protocol for “fecal transplant” for treatment of difficult cases
Transportation and Nursing Identified need to keep chart clean during transport – cover chart in plastic bag during
transportation
Examples of Collaboration
Inter-Nursing Collaboration Sticker on chart in addition to door sign for improved communication
Facilities, Nursing, Infection Prevention Identified areas with limited sinks and installed sinks on multiple floors Installed wall caddies for easy access to PPE Stickers on Alcohol Hand Rub canisters
Admissions Office, Nursing, Infection Prevention Extended Precautions till discharge Cohorting patients during room shortages
Surgeons and Infectious Disease Team Implemented trial of probiotic yogurt in ICU
Infectious Disease Fellows and Pharmacy Reviewed management of CDI cases daily with interventions as necessary
Enhancement of Antimicrobial Stewardship Program – A major collaboration with pharmacy colleagues…
The Case for Antimicrobial Stewardship
As much as 50% of antibiotic use is inappropriate
Inappropriate antibiotic use associated with poor patient outcomes, resistance development, increased health-care costs
Declining antibiotic pipeline in recent years
New Antibiotic Approvals
Modified from Spellberg B et al. Clin Infect Dis; 2008;46:155-64
0
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4
6
8
10
12
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1983-1987 1988-1992 1993-1997 1998-2003 2004-2007
Dellitt TH et al. Clin Infect Dis 2007;44:159-77.
Dellitt TH et al. Clin Infect Dis 2007;44:159-77.
Highlights of the Stewardship Guidelines
Multidisciplinary collaboration: stewardship team, infection control, Pharmacy &Therapeutics
Support from hospital leadership and medical staff Appropriate compensation (ideally through offices of quality/patient
safety) Administrative support to track outcomes 2 core strategies:
Prospective audit with intervention & feedback
Formulary restriction with preauthorization
Dellitt TH et al. Clin Infect Dis 2007;44:159-77.
Antimicrobial Stewardship Strategies
Component IDSA/ SHEA Guideline Strength of Evidence
Implemented at Henry Ford Hospital
Formulary restriction with audit and feedback
AI
Education AIII, BII
Guidelines, pathways AI, AIII
Antimicrobial cycling CII No
Antimicrobial order form BII
Combination therapy CII Not routine
De-escalation AII
Dose optimization AII
IV to PO Conversion AII
Dellitt TH et al. Clin Infect Dis 2007;44:159-77.
Henry Ford Hospital (HFH) Antimicrobial Stewardship Program (ASP)
What is it? A comprehensive system of health-care providers, pathways,
guidelines, order sets, and informatics designed to optimize antimicrobial utilization
Mission statement To improve patient outcomes through optimization of
antimicrobial therapy and support the education of health-care providers in appropriate antimicrobial use
7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training
Key Element Local Action at HFH
Quality and safety coordination of multidisciplinary CDI task force
Pharmacy and antimicrobial subcommittee ownership for antimicrobial stewardship
Recommendations implemented by antimicrobial subcommittee of Pharmacy & Therapeutics
7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training
Key Element Local Action at HFH
Quality and Safety coordination
Strong multidisciplinary involvement with Chief of Infectious Disease and Gastroenterology directly involved
Support from Director of Pharmacy Services, Chief Medical Officer, Hospital Administration
7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training
Key Element Local Action at HFH
Antimicrobial Subcommittee
Stewardship pharmacist
Stewardship rounds with Chief of Infectious Diseases
Infectious Diseases pharmacy residency program added
7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training
Key Element Local Action at HFH
Placing a higher priority on the “stewardship agenda” within existing clinical pharmacy and infectious diseases practice model
Pharmacy resident project dedicated to validation of CDI management algorithm
Infectious diseases fellows performed daily review of C. difficile infected patients
7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training
Key Element Local Action at HFH
Deep dive into C. difficile cases to identify “problem” antibiotics
Stewardship program efficiency improved with implementation of Theradoc® decision support software
Multidisciplinary task force members responsible for disseminating change to their department/ discipline
Presentations at grand rounds and departmental meetings
Policies and guidelines communicated in hard copy and on Intranet
National presentations and posters to describe the work (e.g. C. difficile management algorithm presented at ICAAC 2009)
7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training
Key Element Local Action at HFH
Antimicrobial Stewardship Website:Guidelines and Education
C. difficile Management Pathway
Adapted from: Drugs 2007; 67(4):487-502 and Infection Cont Hosp Epidemiol 2010; 31:431-455.
Treatment success was defined as clinical resolution of CDI by day 14 or end of treatment (EOT) and the absence of complications or relapse
Richardson C et al, abstract 423, IDSA 2009, Philadelphia, PA
Compliance with institutional pathway was associated with improved outcome
Priorities are set by antimicrobial subcommittee, identification of key messages for educational initiatives
Continuous improvement sought:
• Larger role for ID pharmacist and stewardship pharmacist
• More multidisciplinary education, ensure training is at an appropriate level for each group
• Increase involvement of ID fellows, hospital epidemiology, microbiology
7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training
Key Element Local Action at HFH
Follow Through and Accountability
Guidelines are well established and often many eager participants – but challenge is to move process forward
Consistent data/messages to hospital leadership
Problem identified as a priority to leaders Capital and resources
Structure to support accountability Office of Clinical Quality and Safety Leaders and executive committees maintain accountability
Task Force Results
HFH Nosocomial C. diff Rates 2009-2011
0.0
5.0
10.0
15.0
20.0
25.0
30.0
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0,00
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Day
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Rate 23.3 21.7 26.8 27.5 16.0 6.7 13.0 8.7 10.5 7.3 7.5 10.80 8.2 5.89 5.6 9.7 6.2 8.0 8.8 7.4 8.9 10.4 7.3 7.1 6.9 4.7 3.4 3.2 3.4 3.6 5.8 4.4 4.9
Benchmk 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00
J an '09
Feb Mar Apr May J un J ul Aug Sep Oct Nov DecJ an '10
Feb Mar Apr May J un J uly Aug Sep Oct Nov DecJ an '11
Feb Mar Apr May J un J ul Aug Sep
Summary
Implementing improvement projects with sustained results requires: Thorough investigation of problem/issue Communication to key leaders and front line staff Multidisciplinary team approach Process to hold key players accountable with support
from hospital leaders
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