1. Clostridium-Difficile Reduction Utilizing an Interdepartmental Team Approach Mary Jane Lamb RN, IP

2. Objectives Demonstrate how APIE was used to facilitate solving our problem Demonstrate how APIE was used to facilitate solving our problem Discuss how our team approach helped to improve care, reduce C-Diff #s and make staff happier Discuss how our team approach helped to improve care, reduce C-Diff #s and make staff happier Discuss most recent changes to isolation and to lab testing Discuss most recent changes to isolation and to lab testing

3. APIE Assess Assess Plan Plan Initiate Initiate Evaluate Evaluate

4. Assess Problem Identify problem Increase in cases -14 cases in 2007

5. Assess Problem Identify problem Increase in cases - 14 cases in 2007 18 CASES IN 2008 FROM JANUARY TO JUNE

6. Assess Problem Identify problem Increase in cases- 14 cases in 2007 18 cases in 2008 Jan – June 18 cases in 2008 Jan – June Time Line Indentify overlapping patients Indentify overlapping patients Indentify primary departments involved Indentify primary departments involved Observe staff behavior Not isolating until after diagnosis Not isolating until after diagnosis Sharing commodes/toilets Sharing commodes/toilets Carrying dirty laundry out of room to hamper Carrying dirty laundry out of room to hamper

7. Plan 1. Target Zero Task Force – Interdepartmental RNs, CNAs, Education staff, and Environmental staff 2. Review Policy and Procedure 3. Meetings with Patient Care Staff, Environmental Staff and Education Staff and Education

8. Implement 1. Revise Isolation Policies and C-Difficile Policy 1. Revise Isolation Policies and C-Difficile Policy All patients with diarrhea on isolation until cleared All patients with diarrhea on isolation until cleared Strict Contact Isolation Strict Contact Isolation Double bag linen and trash Double bag linen and trash 2. Mandatory education classes for all patient care staff 3. Revise Terminal Cleaning Policy Expanded terminal cleaning Expanded terminal cleaning Wall to floor Wall to floor Privacy curtains Privacy curtains 4. Environmental Service education

9. Implement 5. Add 2 Environmental FTEs for full 24/7 coverage 5. Add 2 Environmental FTEs for full 24/7 coverage

10. Evaluate 1. Staff reactions and concerns Anger over number of isolation rooms Anger over number of isolation rooms Concern over increase in isolation PPE Concern over increase in isolation PPE Concern/anger over extra time involved Concern/anger over extra time involved Concern by Environmental staff that Patient Care staff was not using proper technique Concern by Environmental staff that Patient Care staff was not using proper technique 2. Revise Isolation Policy again 3. Listened to concerns of Patient Care staff and Environmental staff

11. Evaluate Decrease in C-Difficile numbers!!!!! Decrease in C-Difficile numbers!!!!!

12. Immediate decrease in C-Difficile numbers 2007 – 14 cases/21796 X 10000 = Rate 6.0 2007 – 14 cases/21796 X 10000 = Rate 6.0 2008 - 22 cases/21631 X 10000 = Rate 10.0 18 cases in 1 st 6 months 18 cases in 1 st 6 months 4 cases in 2 nd 6 months 4 cases in 2 nd 6 months 2009 - 11 cases/20674 X 10000 = Rate 5.0 2010 - 8 cases/20255 X 10000 = Rate 4.0 2011 - 4 cases/14523 X 10000 = Rate 2.7 through Sept.

13. 2011 Changes New Policy and Procedure New Policy and Procedure Including definition of diarrhea 3 loose stools in 24 hours 3 loose stools in 24 hours Reemphasize when testing can be done only 1 per day only 1 per day Decrease in Isolation time stop isolation 24 hours after diarrhea stops stop isolation 24 hours after diarrhea stops Developed algorithm for C-Dif isolation

14. Patient has loose stool Initiate Contact Plus Isolation No diarrhea or < 3 bouts in 24hs 3 or > loose stool In 24 hours Discontinue isolation d/c stool testing with MD order Obtain MD order for C-Diff test All cultures negative C-Diff positive Continue isolation Loose stools cease X 24 hrs Terminally Clean room D/C Isolation Note: If MD has ordered C-diff test and pt. has formed stool assess need for test with MD. Pt does not need isolation.

15. NEW ISOLATION CATEGORY Contact Plus – used for C-Difficile and other organisms that are not effected by alcohol hand gel/foam Gloves and gowns when entering room to touch anything in environment Gloves and gowns when entering room to touch anything in environment Hand washing with soap and water Hand washing with soap and water

16. Toxigenic C- Difficile Testing NAAT – nucleic acid amplification method This assay utilizes DNA amplification to detect the pathogenicity locus (Paloc) This assay utilizes DNA amplification to detect the pathogenicity locus (Paloc) Sensitivity and Specificity rates>95% Sensitivity and Specificity rates>95% Neg predictive value of 99% Neg predictive value of 99% Pos predictive value of 92% Pos predictive value of 92%

17. Testing Criteria Significant Diarrhea – 3 or more per 24 hours Submit Only 1 unformed stool watery, loose, or taking the form of container watery, loose, or taking the form of container Only 1 specimen will be accepted per diarrheal episode Due to high sensitivity of negative test-no need to repeat Due to high sensitivity of negative test-no need to repeat “Test for cure” for positive test not appropriate because patient may carry toxigenic C-Difficile for months after clinical cure “Test for cure” for positive test not appropriate because patient may carry toxigenic C-Difficile for months after clinical cure Rare form stools may be accepted with approval of Lab Medical Director when requested by physician.

18. Thank You