Transcript Practice - Massachusetts Coalition for the Prevention of Medical Errors

Preventing Transmission of
C. difficile: Practice
Elise Tamplin, M(ASCP), MPH, CIC
Brigham & Women’s Hospital
Objectives
• Discuss practical challenges in
implementing infection control measures
• Illustrate the value of periodic assessment
of compliance
*Excludes NICU
Jul-Sep08
Apr-Jun08
Jan-Mar08
Oct-Dec07
Jul-Sep07
Apr-Jun07
Jan-Mar07
Oct-Dec06
Jul-Sep06
Apr-Jun06
Jan-Mar06
Oct-Dec05
Jul-Sep05
Apr-Jun05
Jan-Mar05
Oct-Dec04
Jul-Sep04
Apr-Jun04
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Jan-Mar04
Number of CDI
cases per 1000 patient days
BWH healthcare-associated CDI rates
1.55
1.19
1.29
1.12 1.06
1.01
1
0.86
0.78 0.78
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Number of cases
CDI leading to colectomy and/or death:
Nosocomial & non-nosocomial cases
8
7
6
5
4
3
2
1
0
Death
Colectomy
Colectomy +/- Death
Challenges
• Preventing acquisition/transmission
• Improving outcomes for patients with
CDI
CDI Control Interventions
• Sentinel event and root cause analysis
• Increase case finding & early
identification—quicker lab turn around time
• Enhance Infection Control measures
• Aggressive CDI management & surgical
evaluation (BWH CDI Treatment Guidelines)
• Staff education
• Minimize antibiotic utilization
Laboratory Testing
• Change in test methodology
– Cytotoxicity assay to EIA
• From 3 day TAT to same day results
– Lower sensitivity
– Need for clinical judgment in
interpretation of negative result
– Increased possibility of false
negatives if specimen taken while on
antibiotics
Basic Infection Control Practices
• Hand hygiene
• Contact precautions for infected patients
• Ensure cleaning and disinfection of
equipment and the environment
• Implement a laboratory-based alert
system
• Conduct CDI surveillance
• Educate patients and families about CDI
Special Approaches to prevent
transmission by healthcare personnel
• Perform hand hygiene with soap and
water after contact with a patient with CDI
– Pro: Alcohol is not sporicidal
– Con: Hand hygiene compliance is lower
for handwashing with soap and water
vs. use of an alcohol-based hand
disinfectant
Special Approaches to prevent spread through
the environment
• Use a hypochlorite-based room cleaning agent
– Pro: Sporocidal and benefit has been reported
in outbreak settings
– Con: Can corrode equipment and can be a
chemical irritant for patients and staff
Special Approaches to prevent
transmission by healthcare personnel
• Prolong the duration of contact
precautions after the patient becomes
asymptomatic until hospital discharge
– Patients may shed C. difficile in their
stool after diarrhea resolves
Bobulsky GS et al. Clin Infect Dis 2008; 46:447–50
New Infection Control Measures
• Enhancements to Contact Precautions
• Contact Precautions Plus
– Soap & water hand hygiene
– Hypochlorite based disinfectantdetergent upon discharge/transfer
– Precautions for duration of admission
Contact Precautions Plus
• Discontinuation upon cessation of
symptoms problematic
• Administration buy-in required for
continuation during entire admission
• Automated “flag” developed by IS like
those for MRSA & VRE but expiring
upon discharge
• Education of Admitting staff re empiric
precaution status
Soap & Water Hand Hygiene
• Major change from routine use of
waterless hand sanitizer
• Visibility of sign key issue
– Several design changes
• Sink availability challenging
– Few in central areas of inpatient units
– Reluctance to use patient room sink
– Hand washing 101
*Bleach-based
Do not remove sign until after room has been cleaned
Hypochlorite Disinfectant
• Infection Control & Safety approvals
• Odor/symptom complaints from staff
- OHS evaluation/tracking
- MNA discussion re safety concerns
- Evaluation of new products
- Change from liquid to impregnated wipes
- Adequacy of surface wetting evaluated
Hypochlorite Disinfectant
• Compliance with use
– Tracking mechanisms
Daily patient log from Infection
Control to Environmental Service
Some rooms still missed
Daily review/verification by ES &
return to Infection Control
– Signs taken down before cleaning
CPP room status added to
housekeeping page
Staff Education
• Physicians
– Early severe patient outcomes helped
– M&M conferences, Grand Rounds, etc.
• Nursing
– Empiric precautions
– Specimen collection prior to treatment
Staff Education
• Support (Environmental Services)
– Balance between emphasis on need for
special measures vs. fostering undue
personal safety concerns
– Regroup with supervisors
• Administrative (Admitting)
– Achieving support for empiric
precautions
CDI Management Guidelines
• Consensus document
– Infection Control
– Infectious Disease
– Medical Intensive Care
– General Surgery
– Microbiology
– Pharmacy
– Nursing
CDI Management Guidelines
• Infection Control Precautions
• Diagnostic testing
• Clinical management of patients
CDI Management Guidelines
• Clinical categories based on specific
clinical criteria
– Appropriate management for each
Stop non-essential medications
 antimicrobials & antiperistaltics
Appropriate antibiotic therapy
Infectious Disease & Surgical consults
Rectal vancomycin (when & how)
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Jan-Mar04
Apr-Jun04
Jul-Sep04
Oct-Dec04
Jan-Mar05
Apr-Jun05
Jul-Sep05
Oct-Dec05
Jan-Mar06
Apr-Jun06
Jul-Sep06
Oct-Dec06
Jan-Mar07
Apr-Jun07
Jul-Sep07
Oct-Dec07
Jan-Mar08
Apr-Jun08
Jul-Sep08
Oct-Dec08
Jan-Mar09
Apr-Jun09
Jul-Sep09
Oct-Dec09
Jan-Mar10
Number of CDAD cases per 1000
patient days
BWH healthcare-associated CDI rates
Contact Precautions Plus
BWH Treatment
1.55
Guidelines
1.29
1.19 1.12
1.061.01
1
0.79
0.86
0.69 0.74
0.780.78
0.7
0.6 0.6
0.6
0.6
0.5 0.5
0.50.5
0.63
0.55
*Excludes NICU
Ja
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Ap ar 0
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Number of cases
Severe CDI leading to colectomy+/-death
Nosocomial vs. non-nosocomial
8
Contact Precautions
Plus
7
6
5
4
3
2
1
0
Nosocomial
Other source
Objectives
• Discuss practical challenges in
implementing infection control measures
• Illustrate value of periodic assessment of
compliance