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Multidisciplinary Partnerships to Reduce Clostridium difficile Infection: A Success Story Laura Johnson, MD Hospital Epidemiologist, Infectious Diseases.

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Presentation on theme: "Multidisciplinary Partnerships to Reduce Clostridium difficile Infection: A Success Story Laura Johnson, MD Hospital Epidemiologist, Infectious Diseases."— Presentation transcript:

1 Multidisciplinary Partnerships to Reduce Clostridium difficile Infection: A Success Story Laura Johnson, MD Hospital Epidemiologist, Infectious Diseases Henry Ford Health System Rachel Chambers, PharmD Pharmacy Specialist, Antimicrobial Stewardship Henry Ford Hospital

2 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

3 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.

4 Yearly Clostridium difficile– related Mortality by Listing on Death Certificates, United States, 1999–2004. Redelings MD, et al. Emerg Infect Dis. 2007;13: Deaths per million population

5 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

6 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

7 Guidelines for C. difficile Prevention and Control

8 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 Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.

9 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

10 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

11 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

12 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

13 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…

14 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: Dellitt TH et al. Clin Infect Dis 2007;44:

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16 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:

17 Antimicrobial Stewardship Strategies ComponentIDSA/ SHEA Guideline Strength of Evidence Implemented at Henry Ford Hospital Formulary restriction with audit and feedback AI EducationAIII, BII Guidelines, pathwaysAI, AIII Antimicrobial cyclingCIINo Antimicrobial order formBII Combination therapyCIINot routine De-escalationAII Dose optimizationAII IV to PO ConversionAII Dellitt TH et al. Clin Infect Dis 2007;44:

18 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

19 7 Strategies for a Successful Stewardship Program Cooke 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

20 7 Strategies for a Successful Stewardship Program Cooke 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

21 7 Strategies for a Successful Stewardship Program Cooke 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

22 7 Strategies for a Successful Stewardship Program Cooke 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

23 7 Strategies for a Successful Stewardship Program Cooke 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

24 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 Program Cooke 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

25 Antimicrobial Stewardship Website: Guidelines and Education

26 C. difficile Management Pathway Adapted from: Drugs 2007; 67(4): and Infection Cont Hosp Epidemiol 2010; 31:

27 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

28 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 Program Cooke 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

29 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

30 Task Force Results

31 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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