Transcript B3 Judi Moscovitch

Evidence-based Care
for the CDI patient
Burnaby Hospital
Quality Forum 2013
February 28, 2013
Vancouver, B.C.
Ivy Chow, Pharmacist
Jan Chan, Registered Dietitian
Judi Moscovitch, Quality Improvement & Patient Safety
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Disclosure
We are unable to identify any potential
conflict of interest and have
nothing to disclose
EXCEPT
A strong bias towards ensuring quality,
safe care delivery to our patients.
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Key Objectives
A. Demographics
B. Care and Management
C. Recommendations
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A. Demographics
724 CDI Cases
HSMR Factor
Q1 2009 – Q3 2011/12
Age
Over 80
60.8%
Gender
Female
51.8%
EHS
97.2%
Residential
17.5%
22 – 365 days
59.5%
Urgent admit
Transfer in
LOS
Comorbidities Cardiovascular 89.0%
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Understand the Patient Journey
B. Care and Management
RN review of 82 patient charts
Pharmacy review of 65/82 charts
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Safety
Antibiotic Usage
98.5% of patients
were on antibiotics
90 days prior to
testing positive
for C difficile.
30.8% of patients had an opportunity
for a prescription or process change.
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Antibiotic Practices
BH CDI Pharmacy Study May 2012
Don't Tx Asymptomatic Bacteriuria
100%
Order cultures first
90%
De-escalate Tx ASAP
80%
Change/Remove Foley Catheter
Appropriate Empiric Choice
Appropriate Shortest Duration
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Effectiveness and Safety
Prevention
26.2% of patients
who were on Proton
Pump Inhibitors
had an opportunity
for prescription
change.
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Medication Management
What can we do?
 Reduce the use of inappropriate
antibiotics
 Review the need for Proton Pump
Inhibitors
 Refer patients to Pharmacy for
medication review
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Effectiveness, Efficiency and Safety
Probiotics
(Saccharomyces Boulardii)
 Pharmacy and Nutrition literature indicates that
Probiotics are not useful after diagnosis of CDI.
 Some literature supports the use of probiotics for
prevention of antibiotic-associated diarrhoea.
41 patients or 64.1%
were prescribed Probiotics
after CDI Diagnosis.
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Effectiveness and Safety
Probiotics
 Saccharomyces Boulardii is contraindicated for immuno-compromised
patients.
 Of the 17 immuno-compromised
patients in this study, 52.9%
received Saccharomyces Boulardii.
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Medication Management
What can we do?
 Review medical literature prior to
prescribing Saccharomyces Boulardii
when:
 Patient has active CDI
 Patient is immuno-compromised
 Patient is in Critical Care Unit
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Effectiveness and Safety
CDI Diarrhoea
 Secretory diarrhoea
 Bowel rest (not eating) does not stop
the diarrhoea
 Increases active secretion
>>> Protein loss
>>> Increased risk of malnutrition
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Effectiveness and Safety
CDI and Diets
NO literature to support diets that are:
 Lactose free
 Fibre free or Low fibre including formulas
 Pre-digested (elemental)
>>>Don’t limit intake
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Diet Recommendation
NPO
Or Hold Tube Feeds
Unless patient shows signs of Ileus, colonic perforation,
Toxic Megacolon or fulminant type of C.difficile
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Nutrition & Hydration
BH CDI Chart Review May 2012
Dietitian Consult
100%
80%
60%
40%
20%
Diet Changed due to CDI
0%
Appropriately Nourished
Avg. > 50% intake daily
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Nutrition Care and Management
What can we do?
 Refer malnourished patients to
Dietitian
 Educate the care team regarding
appropriate diets for CDI pts.
AND
Remind and/or assist patients to wash
their hands before eating
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Management of
Nutrition & Hydration
Effectiveness
BH CDI Chart Review May 2012
Weighed on Admission
100%
80%
Bristol Chart initiated
60%
Weighed when Diarrhea Started
40%
20%
0%
CDI Checklist
In/Out Monitoring Totalled
% Meals Eaten Documented
In/Out Monitoring Started
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Effectiveness and Safety
Nursing Management
 Doing well: Bristol Stool Chart
 Opportunity for Improvement:
 Monitoring of indicators
 Documentation of nutrition & hydration
 Implementation of CDI Checklist
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Nursing Care and Management
What can we do?
 Implement a standardized approach
to Manage Nutrition and Hydration
 Standardize and implement process
for monitoring, treating and
documenting CDI care.
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Effectiveness and Safety
Interventions
 55.4% prescriptions for CDI
deviated from recommended guidelines
 No comprehensive care pathway
for patients not responding
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“CDI should be managed
as a diagnosis in its own right,
with each patient reviewed daily regarding
fluid resuscitation, electrolyte replacement
and nutrition review. Monitor for signs
of increasing severity of disease,
with early referral to ITU
as patients may deteriorate
very rapidly.”
Core Guidance 3.6 Clostridium difficile infection: How to deal with the problem
Department of Health, UK
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Disease Management
What can we do?
 Implement Pre-Printed Orders
for CDI treatment
 Review each case
regularly for response
to interventions
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Effectiveness and Safety
We can
work as an integrated,
comprehensive Health Care TEAM!
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Physician
Nurses and Aides
Dietitian
Pharmacist
Infection Control
Housekeeping
Laundry Services
Who else is on your TEAM?
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C. Recommendations
Care & Management Bundle
1. Manage Medications

Review Antibiotics, PPIs and use of Probiotics
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Review and individualize plan
Monitor intake and output
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
Pre-Printed Orders
A Standardized Care Pathway
2. Manage Nutrition and Hydration
3. Manage the CDI disease process
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Consistent monitoring
Weekly case review
Integrated Team approach
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C. Recommendations
Care & Management Bundle
Don’t Forget!
4. Patient and Family Engagement
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
Patient hand-washing prior to eating
Follow Contact Plus precautions
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Where to Start
www.dh.gov.uk
www.ihi.org
www.saferhealthcarenow.ca
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For more information
please contact:
Jan Chan, Dietitian
Practice Leader
[email protected]
Ivy Chow, Pharmacist
[email protected]
Judi Moscovitch,
Consultant,
Quality Improvement &
Patient Safety
judi.moscovitch@
fraserhealth.ca
What change
can you make
to drive QUALITY CDI care?
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