C Difficile - The Ultimate Challenge: Controlling the Spread

Transcription

1 C Difficile - The Ultimate Challenge: Controlling the Spread Linda R. Greene, RN, MPS, CIC Manager of Infection Prevention Highland Hospital Rochester, NY University of Rochester Medical Center linda_greene@urmc.rochester.edu

2 The Big Picture C difficile lab ID reported through NHSN Proposed for Value Based Purchasing FY 2017

3 The Year 2009

4 A vital Energetic woman Friend, Mother and Grandmother

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8 So what do we need to do? Engage Evaluate Educate Execute The Evidence based Model for Improvement

9 Strategies for Engagement Multidisciplinary Team Senior Leadership Putting names and faces to cases

10 Education

11 C difficile Now rivals MRSA as the most common organism found in hospitals Incidence outside the hospital may be more common than previously thought Associated with increased length of stay, morbidity and mortality

12 Impact of C. difficile infection (CDI) Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually Hospital-acquired, post-discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually Campbell et al. Infect Control Hosp Epidemiol. 2009:30: Dubberke et al. Emerg Infect Dis. 2008;14: Dubberke et al. Clin Infect Dis. 2008;46: Elixhauser et al. HCUP Statistical Brief #

13 Pathogenesis C. difficile is acquired by ingestion of spores from the hospital environment or hands of healthcare personnel Alteration of the intestinal flora by antibiotics leads to C. difficile proliferation in the colon Colonization Advanced age Multiple comorbidies No antibody to Toxin A/B Antibody to Toxin A/B C. difficile diarrhea No diarrhea

14 Ingested Normal flora interrupted Small Intestine Spores Germinate C Difficile toxins monocytes Pseudomembrane Toxin A attracts neutrophils and monocytes, and toxin B degrades the colonic epithelial cells, both leading to colitis, pseudomembrane formation, and watery diarrhea Neutrophils C difficile reproduces in the intestinal crypts, releasing toxins A and B, causing severe inflammation. Mucous and cellular debrisare expelled, leading to the formation of pseudomembranes

15 Pseudomembrenous Colitis Wolf P, Kasyan A N, Engl J - Med 2005;353:2491

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17 I just touched the bed rail 100-1,000 bacteria transferred by: Pulling patients up in bed Taking a blood pressure or pulse Touching a patient s hand Rolling patients over

18 O² sat monitor Stethoscope

19 Keyboard & Mouse Med Keyboard

20 C Difficile in the enviornment C. difficile forms an endospore or a dormant state with increased resistance when conditions in the human or animal body or the environment become unfavorable for it to survive in its vegetative (actively growing) state. In the endospore stage, C. difficile spores will not be destroyed on environmental surfaces by disinfectants

21 Transmission- Fecal Oral Route o Mainly by direct contact with the hands of HCWs o Autoinoculation (oral ingestion) o Shed in feces o Indirect contact (inanimate objects such as commodes, etc) o Environmental contamination spores can survive for months in the environment

22 What s Wrong With This Picture

23 Another One

24 What are the symptoms of Cdiff? watery diarrhea fever loss of appetite nausea abdominal pain/tenderness (Be wary of lack of stools)

25 CDI 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 Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S SEE ALSO: Cohen SP, et al. SHEA/IDSA Clinical Practice Guideline, ICHE May 2010

26 Bundle Monitoring Tool

27 The Compendium

28 Outbreak or Hyper-endemic Setting only

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30 Hyper-endemic levels

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34 Other Issues Lab ID is a marker. May also pick up colonization What are your criteria for sending a specimen Any Inappropriate testing? Testing methods PCR 2 STEP Toxin- A and B antigen

35 Renewed Respect for Role of the Environment: Who s Been in the Room Before or With You? Huang SS (2006); Drees M (2008); Zhou Q (2008); Moore C (2008);Hamel M (2010) All documented increased risk of acquisition of VRE, MRSA, &/or CDI when admitted to room where prior occupant had one of these or if in multi-occupancy room So what s the answer?

36 What s The Answer? They need to get a life Keep Going No Doesn t Look clean yet

37 Sharing Best Practices NYC- Dr. Brian Koll Administrative Clinical Physician and Nursing Champions

38 Teach Teamwork Infection Prevention Coach Training Program Monitor and enforce practices Problem-solve Share and spread best practices Participation in hospital forums Environment of Care

39 Measuring and assessing effectiveness Reducing CDI Feedback Sustainability Dissemination and Spread Web based and electronic communication

40 Infection Prevention Bundles

41 C. difficile Infection Prevention Bundle Hand hygiene (washing with soap and water for C. difficile) Contact precautions Sign placement PPE readily available / used Dedicated rectal thermometers Patient placement private room vs. cohorting vs. shared Bathrooms dedicated vs. shared vs. commode Transport precautions Environmental cleaning hypochlorite-based disinfectant daily and terminal cleaning procedures

42 Environmental Checklist

43 New Technologies

44 Other Measures Prevent other Infections UTI S use of florquinoles highly associated with C Difficile

45 The Bottom Line It s like eating an elephant 1 bite at a time