Improving Patient Outcomes for both Nosocomial and Community- Acquired Cases of Clostridium difficile Infection (CDI) in Tallaght Hospital NIAMH FITZGERALD

C. difficile  Part of our normal gastrointestinal flora  Use and misuse of antibiotics predisposes to CDI infection by disturbing our normal gut flora allowing overgrowth of C. diff and toxin production  Transmitted by the faecal-oral route

C. difficile  Leading cause of infectious, nosocomial diarrhoea in developed countries  Illness ranges from mild diarrhoea to potentially fatal colitis  Incidence of C. diff increases with length of stay

Problem Statement  Inadequate in-house C. difficile service; time consuming and expensive

Project Goal  Reduce the turnaround time of the assay in a cost-effective manner

Background and Objectives  For the patient: Reduce the time to diagnosis of CDI and start treatment protocols sooner, where necessary  For the hospital : To ensure hospital compliance with National Clinical Guidelines for the Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland

Background and Objectives  For the department : Reduce the “hands on time of testing” to enable our staff to streamline workflows. Reduce the cost burden of C. difficile testing on the laboratory.  For the microbiology staff : To educate staff in the use of real-time molecular methodology with the aim of expanding this service in the future.

Current State “As Is” Process Map

Measures Undertaken  A quality improvement project was undertaken as part of an in-house project management training course  Change management tools were used, starting with a business case and project initiation document

Measures Undertaken  Business Case and Project Initiation Document (PID) Project RisksRisk Mitigation 1. Technical errors with equipment Seek advice /recommendations from colleagues in other hospitals with experience of the technology 2. Benching installation/delayed start Liaise with technical services/highlight urgency/keep communicating.

Measures Undertaken  A stakeholder analysis was completed to clarify what users of our service required  This included our infection control team and consultant microbiologists

Translating Voice of the Customer to Critical to Quality

Methods Used  Plan, Do, Study, Act (PDSA) small cycles of change were used starting with a testing and validation phase and moving into a pilot study  Complete change in test methodology  Change in test frequency  Introduction of a toxin test

Future State Map

Turnaround Time Run Chart Change 1

Outcomes  Currently detecting higher numbers of CDI cases due to more extensive testing and a more sensitive assay  Leads to quicker diagnosis and treatment of our patients with effective infection control measures in place. This lessens morbidity, reduces length of stay and offers better patient outcomes

Outcomes  The turnaround time for our C. difficile assay service reduced from 85% of tests in 3 days to >85% of tests in <1.0 day  Our hospital is now compliant with National Guidelines testing all diarrhoeal stool samples for C. difficile (both hospital and community sources)  The laboratory cost per test has reduced by an average of €9 which, based on our current laboratory test figures, will yield cost savings of approximately €20,000 per year

Potential Savings  Costs of CDI cases are impacted by drug therapy, hospital readmissions, decontamination and litigation but also ward closures and staffing resources both in the hospital and the community  Based on a review of European literature the additional cost per case attributed to CDI ranged between €5,798 to €11,202, averaging €8,516. When combined with Irish case figures this gives the estimated additional cost of treating inpatients with CDI in 2013 ranging from € million.

Potential Savings  The case numbers in Tallaght Hospital for 2014 were 75 (extrapolated cost €638,700). A reduction in case numbers could yield the following additional savings: 5% €31,935 per annum 10% €63,870 per annum 15% €127,740 per annum

Future  We have approximately 33% of our staff trained in real-time molecular methodologies and will roll this out further over the coming months. We are now targeting bringing other molecular assays in- house  Over time we believe we will see a decrease in our CDI cases as these measures take full effect

Acknowledgements I would like to thank the following people: Sponsor: Dr. Gerard Boran Team members: Nuala Kealy, Medical Scientist Eddie McCullagh, Chief Medical Scientist Mentor: Mary Hickey, Quality improvement Lead