C. Difficile Prevention Collaborative: Learning and change in Massachusetts September 2012 Susanne Salem-Schatz, Sc.D. HealthCare Quality Initiatives Sharon Benjamin, Ph.D. Alchemy 1

Clostridium difficile infection (CDI) Anaerobic bacteria - spore producing bacillus Most common cause of infectious diarrhea in healthcare facilities New strain appears to produce greater quantities of Toxin A and B resulting in dire consequences in many cases Clinically manifests in a variety of forms from mild diarrhea to toxic megacolon (rupture and sepsis) and subsequent death can occur Risk factors – Elderly > 65 years of age more susceptible – Antimicrobial therapy – Advancing age – Tube feeding – Proton Pump Inhibitors (PPIs) – Extended length of stay

Clostridium difficile infection (CDI) Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually Hospital-acquired, post-discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually

Clostridium difficile infection (CDI) Precautions to prevent CDI are crucial to decrease morbidity and mortality associated with this disease including: Effective hand-hygiene (alcohol hand sanitizer is not sporicidal and is controversial in practice) Prompt testing and sharing of information Isolation precautions Communication Environmental cleaning including patient care equipment

MA CDI Prevention Collaborative : Key features  Statewide partnership and collaboration  Multidisciplinary teams including representatives from infection prevention, quality, clinical leadership, microbiology, pharmacy and environmental services;  A common set of practice recommendations in the areas of surveillance testing, isolation policies, hand hygiene, contact precautions, and environmental cleaning and disinfection; with additional support for antibiotic stewardship  3 statewide full day learning and sharing workshops and regional workshops featuring expert presentations, highlighting accomplishments of Collaborative participants, and teaching /practicing staff engagement strategies  Improvement frameworks including the Model for Improvement (including PDSA, or small tests of change), and culture change strategies such as Positive Deviance to support staff engagement;  Common measurement and reporting tools in Excel based on NHSN HAI definitions MA CDI Prevention Collaborative

N=17 What hospitals did and how MA CDI Prevention Collaborative

HA-CDI Reduction in MA Collaborative MA CDI Prevention Collaborative

One of 27 Stories MA CDI Prevention Collaborative

Lessons Learned Improvement requires hard work, time, & is supported by building on long term relationships and collaboration Value of shared data to track improvement and solve problems Value of an improvement framework: aims, measures and small tests of change MA CDI Prevention Collaborative

Lessons Learned Engaged front line staff make changes happen! Adapt changes locally Balance serious messages with creative approaches to engage staff and support culture of quality MA CDI Prevention Collaborative

MA CDI Partnership Prevention Collaborative : Key features  Statewide partnership and collaboration  Worked with clusters of 17 hospitals and 70 partnered long term care facilities (active engagement by about 14 hospitals and 35 long term care facilities)  Leveraged hospital expertise by encouraging cross facility efforts and coaching  Multidisciplinary teams including representatives from infection prevention, quality, clinical leadership, microbiology, pharmacy and environmental services;  A common set of practice recommendations in the areas of surveillance testing, isolation policies, hand hygiene, contact precautions, and environmental cleaning and disinfection; with additional support for antibiotic stewardship  2 statewide full day learning and sharing workshops and regional workshops featuring expert presentations on CDI prevention practices, antibiotic stewardship, teaching /practicing staff engagement strategies  Improvement frameworks including the Model for Improvement (including PDSA, or small tests of change), and culture change strategies such as Positive Deviance to support staff engagement;  Common measurement and reporting tools in Excel based on NHSN HAI definitions

Small numbers and short timeframe make it hard to document improvement

Stories of Success

Approaches used

What they said Value of activities with Partner Hospital – 10 on a scale of 1-10 Most innovative? – CNAs loved the commode liners! What helped team work well together? – Talking with the front line staff about what they think. Showing rates of infection to department heads. Did new things to engage leadership, front line staff and residents/families

They were part of an active cluster

And had active multidisciplinary teams

Milford Cluster November 2011June 2012 HospitalSkilled Nursing

How LTCFs thought partner hospital most helpful? We get many admissions from M Hospital. They always let us know either before or at admission if a patient has c-diff infection. Providing information, education and demonstration of procedures and what worked and did work for them. We use the hospital lab for our lab work;this is invaluable for tracking and we are informed concerning any trends identified. The hospital staff is available for consult, including the MD & Infection Prevention Nurse. Sharing their expertise and information

What the hospital thought was valuable Monthly meetings where there is open collaboration and sharing of knowledge. Involvement of the MRMC Environment of Care Department. They reached out to facilities with help in engaging staff, providing education. MRMC laboratory involvement with infection prevention and control meetings at each facility. Initial meet and greet informative breakfast meeting was given by MRMC to "ALL" outside long term care facilities. We closed each meeting by each of us stating what would be our next steps or project.

What helped cluster work well together & fostered success? Willingness to communicate successes and failures. There is truly a collaborative feeling to our relationships. This, to a degree, formalized what was already a solid working relationship between the medical center and facilities in our communities. "It takes a village." Working together as a community increases our chances for success.

What we’ve learned Relationship – centered approach Engaging leadership and the front lines Create opportunities for active learning Combine existing evidence with opportunities for discovery and reinvention Leverage organization’s self interest to create broader communities of change

Where we struggle Dynamic tension between approaches that involve direct coaching and the prevalent learning collaborative models Balancing participant expectations and what we know about adult learning How do we leverage multiple frameworks in a resource-limited environment?