1. Maureen Spencer, RN, M.Ed., CIC Infection Control Manager New England Baptist Hospital, Boston, MA

2. Presentation Objectives  Demonstrate how one hospital used the new CDI surveillance definitions to identify an increase of CDI on one nursing unit.  Describe enhanced environmental controls to reduce transmission of CDI  Describe the new Clostridium difficile Infection (CDI) Collaborative Definition

3. New England Baptist Hospital June 2008  Received the CDI Surveillance Working Group CDI definitions at the APIC Conference 2008 in Denver  ICP presented the new surveillance definitions to the Infection Control Committee  Reclassified cases in July 2008  Identified one nursing unit with 76% of the cases of HA- CDI  Contributing Factors:  Several of the patients had also been in the ICU and were transferred in an ICU bed rather than stretcher, and often went back and forth between the two units in the same bed  Patients were being removed from Special Contact Precautions after diarrhea stopped, prior to discharge – housekeeping didn’t know the room needed to be cleaned with bleach or cubicle curtains changed

4. New Surveillance Definitions

5. Initial Investigation August 2008  FY08 = 24 Patients with positive C.difficile titers  – 3 from outpatient locations  –21 from inpatients (87.5%) Nursing Unit - Developed Signs and Symptoms:  –J4 East 16/21 cases (76%)  –L 5 1/21 cases ( 5%)  –5 East 3/21 cases (14%)  –ICU 1/21 cases ( 5%) 3 of 16 Jenks4East cases were in room 465  - 2 of the CA-CDI (community-acquired) cases were in room 465

6. Poster we presented at APIC 2007 showing CDI with room association – 28 patients had been in 42 rooms!

7. FY2008 - NEBH Cases Per New Definitions

8. C.Difficile Team - August 08  Formation of C.Difficile Team:  Dr. Camer (Chief of Surgery)  Dr. Lui (Chief of Gastroenterology), Sharon Connolly, RN – Nurse Manager, Sue Cohen,MT (ASCP) Microbiology Supervisor,  Maureen Spencer, RN, Infection Control  Met weekly, reviewed literature, formulated control measures, designed a retrospective case review, and educational offerings  Instituted Use of Chlorox Bleach Wipes  Enhanced Education for Staff  Changed patient transfer procedure  Stretcher (not in bed)  Retrospective Case Review of all CDI cases

9. Retrospective Case Review FY2008 N=34  Proton pump inhibitors 13 (67%)  Cancer 12 (35%)  Fluorquinolone use 9 (26%)  Obesity 9 (26%)  CT Scan before onset 6 (18%)  MRSA Colonization 5 (15%)  VRE Colonization 3 ( 9%)  Diabetes 3 ( 9%)

10. Enhanced Prevention Education Transfers between units on stretchers versus contaminated bed Green tag flagging system for cleaned equipment Dinamap baskets with sanicloths and not allowed in precautions rooms Spatial Separation of precaution cases Bleach wipes for all precaution rooms Enhanced cleaning of equipment

11. Nursing Unit Decontamination  Decontaminated 19 rooms with dri-mist particle generator that breaks down disinfectant into microscopic, negatively charged ion particulates.  These particulates are smaller than one micron in diameter and can access ALL surfaces of a room.  Particulates are negatively charged and stick to positively charged contaminants  Some evidence it will kill spores (testing done by VAMC, W. Palm Beach, FL – biological indicators (G. stearothermophilus) placed around the room in areas to being treated – all were negative)  Three day period – lease arrangement with company  Cost: ~$5000.00 for 19 rooms  Issues: set off smoke detectors, prep time to seal ventilation and doors

12. NEBH CDI Rates FY08-FY10 FY08FY09FY10 (Oct-Apr) Total HAI21Total HAI13Total HAI7 Patient Days28914Patient Days28382Patient Days15967 Rate/10,000 PtDays7.3 Rate/10,000 PtDays4.6 Rate/10,000 PtDays4.4 (37% reduction) Hospital Onset13Hospital Onset10Hospital Onset5 Rate/10,000 PtDays4.5 Rate/10,000 PtDays3.5 Rate/10,000 PtDays3.1 (22% reduction) Comm Onset HA8 Comm Onset HA3Comm Onset HA2 Rate/10,000 PtDays2.8 Rate/10,000 PtDays1.1Rate/PtDays1.2 (61% reduction)

13. Interventions in 2010  Decontamination of the Ambulatory Care Unit (our “mini-ER”) after observing commode handling procedures and use of community bathroom by CDI patients.  Decontamination will be done in July on the night shift with a vaporized hydrogen peroxide room decontaminator.  Implemented commode liners to eliminate disposal of liquid waste by staff.

15. Healthcare Facility Acute Care Hospital Rehabilitation Facility Nursing Home Other Chronic Care A case of C. difficile is defined as a case with diarrhea without other known etiology. The stool sample will yield a positive result for laboratory assay for C. difficile toxin A and/or B (or positive PCR) For purposes of this collaborative, C. difficile is limited to laboratory confirmed cases. This collaborative will track healthcare facility associated C. difficile C. difficile (CDI) Collaborative Definition

16. A patient classified as having a case of healthcare facility associated C. difficile is defined as a patient who develops diarrhea more than 48 hours after admission OR A patient classified as having any symptoms that develop within 48 hours after discharge to another healthcare facility. OR A patient discharged to home with lab confirmed C.diffIcile within 28 days from the day of discharge and no intervening admissions.. (Day of discharge counts as day 0) Also counts if C.difficile is identified on readmission to your facility. If the time of admission and/ or the time of diarrhea onset and/or the time stool was collected are not available, CDI can be considered to be healthcare facility onset if onset of diarrhea, with a positive stool occurs on or after the third calendar day after the day of admission (which is day zero).

17. EACH PATIENT ONLY COUNTS ONCE Within 8 weeks of index diagnosis C. difficile (CDI) Collaborative Definition A patient readmitted after 8 weeks counts as a new patient /case (E.g. Monday admit, day 4 = Thursday) FACILITY HA-CDI RATE # HA CDI cases / 10,000 Patient Days (exclude NICU days)

18. Example of a Run Chart

19. Presentation Objectives  Demonstrate how one hospital used the new CDI surveillance definitions to identify an increase of CDI on one nursing unit.  Describe enhanced environmental controls to reduce transmission of CDI  Describe the new Clostridium difficile Infection (CDI) Collaborative Definition

20. THE END THANK YOU