C. Difficile Testing Protocol Caroline Donovan, RN, BSN, ONC- Infection Control Practitioner Abegail Pangan, RN, MSN, CIC- Infection Control Practitioner U.S. NEWS & WORLD REPORT 2017 2018 RANKINGS Acute Care Hospital (Orthopedic Specialty Hospital) New York City 215 Beds 40 Operating Rooms 30,000 Procedures 352 Physicians
What makes HSS Different? Orthopedic specialty hospital 30,000 procedures annually Hip replacements (HPRO) & Knee replacements (KPRO) Only NHSN Reportable procedures 12,000 13,000 HPRO & KPRO procedures annually 2 C. Diff Prevention
Clostridium Difficile Effects Patient Outcomes 3
Clostridium Difficile Testing Acceptable Specimen Loose or watery stool specimen Suspected ileus caused by infection: verbal communication with lab occurs prior to submission of sample Rejection Criteria Specimens that are not liquid or soft Specimens from infants under 1 year old should be discouraged Specimen received greater than 24 hours after collection Rectal swab specimens Test for cure or testing from asymptomatic individuals 4
Clostridium Difficile Laboratory Testing Stool Culture for toxin-producing C. diff (*Gold Standard) Most accurate, but has slow turn around of up to 3 days; not clinically feasible Nucleic Acid Amplified Tests (NAAT) including Polymerase Chain Reaction (PCR) High sensitivity and high specificity May lead to false positive results and increase detection of colonizers Enzyme Immunoassay (EIA) Rapid results, high specificity, but low sensitivity Glutamate Dehydrogenase (GDH) GDH is an enzyme produced in large amounts with toxins A and B High sensitivity, but low specificity 5
NHSN C. difficile Lab ID Event CDI-positive laboratory assay: All non duplicate positive laboratory test result for C. diff toxin A and/or B, (includes molecular and toxin assays) tested on an unformed stool specimen 6
Problem 7
Antimicrobial Stewardship 8
The C.difficile algorithm was created to help guide clinicians in the proper ordering of C. difficile testing. It is located in the C. difficile hospital policy. 9
What Our EMR Implementation Allowed Us To Do Infection Preventionist In House Staff Isolation / Infection Mismatch report Laboratory based alert system that identifies and flag infection status Automatic Contact isolation order is entered when test is ordered Infection Control Line listing of positive test in a time period Alert if C. diff test is ordered which allows early identification if appropriate C. diff testing is performed Best Practice Advisory House census list- identifies isolation/ infection status Positive test auto flagged in the patient s infection banner Nurse will see the contact isolation order once C. diff test is enteredpreemptive isolation Allows communication of any increased trend of cases in a unit Nurses avoid specimen collection if testing is inappropriate End user is informed of the C. diff testing algorithm 10
Process and Governance 11
EPIC replicated the algorithm in the form of a Best Practice Advisory (BPA) for prescribers to review when ordering testing. 12
Selecting All Questions Reviewed is required in order to select the Accept button. 13
Once accepted, both Clostridium Difficile Toxin and Contact Isolation Status display in the New Orders to be signed list. If a patient is already on Contact Precautions, only testing will populate. 14
When the test is ordered, Infection Control Practitioners are alerted in the Isolation and Infection Census by the automatic Contact Isolation order and an alert seen in the C.diff Order column. Staff members are able view the Isolation status on the EPIC banner. 15 Staff members now see both Isolation and Infection on the EPIC banner. The Infection Control Practitioners or Microbiology department adds the infection type once the test is positive in the infection tab to clarify for staff members why the patient is on Contact Isolation.
C.difficile Tests Received by Microbiology Lab 35 30 25 20 Go Live for Algorithm: 03/16/17 15 Tests 10 5 0 16
Test Sent and Positive Results 35 30 25 Go Live for Algorithm: 03/16/17 20 15 10 Tests Positive Hospital onset 5 0 17
Better Patient Outcomes Decreased unnecessary testing and treatment Early identification and prompt Contact Isolation Increased communication of patient infection status to in house staff Improved active surveillance and reporting Utilization of Antibiotic Stewardship 18