1. Clostridium Difficile
Improvement Action Network (IAN)
Clostridium Difficile
Virtual Session
June 19, 2017

2. IAN Objectives
Participating hospitals will share current barriers to CDI prevention and what they hope to get from today’s session
The Hospital Perspective - Mentor Hospital Sharing
Aspirus Wausau Hospital
HSHS – St. Mary’s Hospital Medical Center
Aurora Medical Center – Manitowoc County
Q & A Session
30/60/90 Day Action Planning
Next Steps

3. Round Robin – Gap Analysis and Goals
Each hospital team reports off on what their biggest barrier to CDI prevention has been and what they would like to take away from today’s session.

4. C.diff Project Report Aspirus Wausau Hospital

5. AWH C.diff Baseline
Baseline look at how AWH compared with other WI Hospitals at project Kickoff

6. Critical Project ~ AWH C. diff Rates
Pillar goal for FY 2017: < 29 C. diff cases

7. C.diff Goals & Objectives
Decrease the number C.diff cases at Aspirus Wausau Hospital which will improve patient safety
This will result in a reduction of reportable case to regulatory agencies
Targeted areas for improvement
Hand Hygiene/ Isolation precautions
Cleaning/Disinfection of equipment
Environmental cleaning
Antibiotic Stewardship
C.diff Testing
Education
Communication
Auditing .

8. C.diff Project Details Hand Hygiene
Standardization of Hand Hygiene products (soaps and lotion)
Multiple survey methods showed there was a gap in employee understanding of the process to report adverse reactions to Hand Hygiene. This process is now included in the training
To promote Hand Hygiene messaging and processes, Project Executive handed out thank yous with existing Hospital Approved lotion product

9. C.diff Project Details Cleaning Patient Care Equipment
Processes in place so staff know what they are accountable to clean, and how to clean
Also looking into a 3rd party equipment cleaning management company to determine if there is value in having them handle some of this work

10. Cleaning Matrix

11. C.diff Project Details Surfacide UV Light Room Disinfection System
Training & Implementation of System
Audits include Daily Bathroom Cleaning
Terminal Cleaning is done at discharge
12/2016 – 5/ % of rooms were terminally treated.
Patient Room Cleaning
EVS Reviewed, updated and trained staff on new processes

12. Cleaning Effectiveness
EVS monitors the thoroughness of cleaning on critical surfaces in patient rooms using a fluorescent gel technique to objectively measure cleaning quality.

13. C.diff Project Details Antibiotic Stewardship Plan
Antibiotic Sub-Committee developed an action plan and goals that meet the Joint Commission Standards
Activities will be reported through Pharmacy and Therapeutics Committee and the Infection Control Committee
Their first pilot project is working with hospitalists to develop a process for a 72 hour timeout

14. Antimicrobial Stewardship Data

15. C.diff Project Details C.diff Testing Developed the testing algorithm
Stringent specimen rejection criteria
Automated in Epic

16. Testing Algorithm

17. Specimen rejection criteria

18. C.diff Project Details ~ Education
Providers
Clinical Staff
Provider communication about C.diff issues, including testing recommendations
Med Staff Friday C.diff Lunch & Learn, included Surfacide lights
Provider Hand Hygiene education including the change in expectations regarding crossing the threshold (posters in lounge)
Healthstream ELearning
Curriculum includes training on management of patients with C.diff, and touches on all of the project elements requiring education
Return demonstrations competencies for Hand Hygiene and PPE Donning and Doffing

19. C.diff Project Details Communication
Utilize score card & visual management
Will continue daily rounding, communication boards, and huddles (EVS staff added to Nursing huddles)

20. C.diff Project Details Audits
Handwashing: All Departments to start when training is complete in mid-February. (To include crossing the threshold)
Product Usage: Measuring product usage as a surrogate measure of compliance
Isolation procedures compliance monitoring: updated policy to keep C.diff patients in isolation until discharge
Daily CHG Bathing: Report of patients with factors listed in the protocol who received a daily bath
Daily report of C.diff testing
EVS audits including daily disinfectant concentration checks, terminal room cleaning effectiveness with fluorescent marking system & Surfacide disinfection

21. Preventing Hospital Onset C
Preventing Hospital Onset C. difficile HSHS Eastern Wisconsin Division June 2017

22. HSHS Eastern Wisconsin Division
Hospital Sisters Health System (HSHS) is a multi-institutional health care system that cares for patient in 12 communities (15 hospitals) in Illinois and Wisconsin
Eastern Wisconsin Division
St. Mary’s Hospital Medical Center—Green Bay
St. Nicholas Hospital—Sheboygan
St. Vincent Hospital—Green Bay
St. Clare Memorial—Oconto Falls

23. Our Story Begins: Increasing Risk
Community C. diff
C. diff Burden in Hospital
We talked about hospitalization being a risk factor but it is also important to understand:
C.Diff is becoming more and more common as community onset infection.
This incidence leads to increased risk for hospital onset cases due to increased burden of bacteria within hospital.
What was our peak 2011?

24. C. diff Prevention Initiatives Prior To 2015
August 2011:
Bleaching of all rooms on discharge at St. Vincent’s
March 2013:
Bleaching of all rooms on discharge at St. Mary’s and St. Nicholas
July 2013:
Transition to Joint Commission’s Targeted Solutions Tool for Hand Hygiene observations
April 2014:
C. diff Screening on admission
September 2014:
St. Clare became part of HSHS System
Bleaching of all rooms on discharge process adopted
Here is a background on our efforts prior to the drivers that really made a difference
Bleach cleaning:
started at SVGB where highest number of hospital onset Cdiff,
later became standard at SMGB and SNS as community onset Cdiff case numbers rose
TST and Hand hygiene
Structured to identify:
contributing causes for non-compliance
health care role compliance
Structured for objective results :
standardized training and observation method s
Easy to run department specific Hand hygiene Reports in development
C. Diff screen added to Epic,
all patients screened on admit to identify cases early to meet quality goals & increase safety

25. Our Approach
Identify what standards of care we expect in taking care of our patients
How do we operationalize/make it easier for nursing
Available at the point of care

26. Approach to Prevention: March 2015
C. diff Bundle
Elements of the standards of care
Bundle of care for every patient every time
Operationalizing it—making it easy for nursing care for patient’s every patient every time
System collaboration:
HSHS created a work group to collaborate on prevention efforts.
After months of work and multiple levels of collaboration throughout the system a C. diff Bundle for caregivers was and develop .
This bundle of resources is located in Epic via hyperlink or from a “forms” tab so nurses or physicians do not need to leave Epic to get the information they need.
This bundle went live the end of March amidst the beginnings of a rising trend of hospital onset C.diff cases

27. Protecting Our Patients Using the C. diff Bundle
The C. diff Bundle is a one page document that provides guidance for the care of C. diff patients
Accessible at the Point of Care within the Best Practice Advisory – if the patient has a C. diff Screening score of 2 or greater
Located in any intervention that has the diarrhea screen as well as in Patient Forms/Hyperlinked Documents in EPIC
Contains links to additional documents to care related resources
Operationalize and making this easier for nursing
Attachments to this presentation are some of the resources in the bundle. These are hyperlinked, so the nurse can easily click on the resource hyperlink and go to that particular resource

28. C. diff Bundle

29. C. diff Bundle Content Early Recognition Hand Hygiene
Environmental Cleaning
Patient Transportation Techniques
Patient & Family Education
Key Components of the bundle

30. Early Recognition for C. diff
Complete C. diff Risk Assessment screening in the ED & with each Admission
If score is 2 or greater, initiate the C. diff protocol
Automatically triggers nursing to order C. diff testing
Automatically triggers nursing to place patient in special contact precautions
I talked to you about our approach and the overall C diff bundle
Now I want to talk to you about one critical part of the bundle is screening of patient’s for C diff

31. C. diff Screening Epic Screenshot
Complete C. diff Risk Assessment screening with each admission
This is the assessment that will trigger the best practice alerts

32. C. diff BPA
Prescriptive and easy to use for the nurses

33. A New Call to Action
Where will the next Hospital Acquired C. diff infection show up?
How could it happen on our unit?
Leveraging Communication Venues
Daily Hospital Safety Huddle
Department Huddles with C. diff
Multi - Discipline Collaboration
Clinical Excellence
Dyad Co-Leadership Nursing and Quality
To develop a culture of innovation and clinical excellence leading to quality premier hospital network
Apparent Cause Analysis
Now we are going to turn to another tactic
Spring 2016 Hospital Safety Huddle: Daily reports by Infection Prevention for each hospital :
Current number of C diff positive patients and location
Number of those that are Hospital acquired
AND Number of Rule out
Leaders would then take the information and huddle with their colleagues, asking
Where will the next hospital acquired C diff infection show up?
How could it happen on our unit
After several months of daily reports, the information became more like “white noise”. So, we changed our tactics to only reporting to safety huddle with any urgent situations (increase in C diff cases throughout hospitals) or with any significant learnings from our ACA’s that can be huddled on a department level
Multidiscipline Collaboration
Clinical Excellence—Team of Nursing Leaders & Facilitators, Quality Leaders & Facilitators, Infection Prevention, Service Line Executive Directors/designees and Nurse Practice Council Representative
Infection Prevention is participating and collaborating with Clinical Excellence to operationalize C diff preventive interventions and decrease/eliminate C diff and other HAI
Apparent Cause Analysis: Nurse leaders and frontline staff participating on apparent cause analysis of hospital onset C. diff infections to identify process breakdown and opportunities for improvement

34. Apparent Cause Evaluation
Common C. diff Apparent Causality Cross walk
Case
Cause
Cleaning Environment opportunities x
Lapses in PPE use
Misapplication of Isolation principles
Patient Family/Visitor PPE
This table shows trends that have been identified from ACA’s
Common Cause as you see is the misapplication of isolation principles

35. Improvement Steps Fall 2016
C. diff Risk Assessment Screening on Hospital Days 2 and 3
Video for Donning and Doffing of PPE
Standardization of Location of PPE
Family/Visitor Focus Signage
Use Principles of Human Factors Engineering
Look at the design of signs and equipment so we can improve the usability
Paid attention to usability of this cart so that anyone coming upon the cart, it is easy to use and follow

36. April 2014, C. diff Risk Assessment on admission into Epic
EWD
HSHS EWD C. diff
April 2014, C. diff Risk Assessment on admission into Epic
Have we made a difference?

37. St. Mary’s

38. C. difficile Colonization
3% -7% of healthy adults
4.4% - 15% on admission to hospital
50% - in a LTC
7% - 21% hospitalized adults
4% - 15% at time of admission
Wisconsin State Conference Presentation by Barbara DeBaun
Focus, this is a problem
We want to make sure that we are over testing

39. Are We Over- Diagnosing C. difficile Infection?
Diarrhea is frequent among those with healthcare exposures
C. difficile infection (CDI) affects < 1% of hospitalized patients
90% of hospital onset diarrhea is not due to CDI
Tube feeding
Laxatives
Enemas
Medications
Other infections
Underlying disease

40. C. difficile Improvement Focus 2017
Staff and provider education
Infectious Disease physician and Infection Preventionist
After day 3, prior to sending down specimen for C diff, nursing and providers are encouraged to have conversation as to judicial sending of specimens. Colleagues and/or providers have open door policy to consult Infectious Disease. (Infection Preventionist as needed)
Looking at the whole picture and not just the toilet
Has the patient had any laxatives of any form? (including prune juice)
Tube feedings?
Underlying diseases?
Does the patient have a fever?
Elevated WBC’s?
Does the patient have abdominal pain, cramping, bloating?

41. Thank You
Thank You to Barbara DeBaun, RN, MSN, CIC Improvement Advisor For allowing me to use information from her Wisconsin State APIC 2017 Presentation

42. Clostridium difficle Improvement Action Network
Aurora Medical Center Manitowoc County
June 2017

43. Our Hospital: Our Patients: 66 Bed Acute Care Hospital 4 Nursing Units
ICU/Stepdown 6 ICU bes
Medical Oncology
Surgical
Women’s Health/ OB
Emergency Department
Surgery both Inpatient and Same Day
GI Lab
Wound Clinic/ Hyperbaric
Ancillary Departments
Tertiary Access Aurora Baycare
EPIC EMR
Our Patients:
ALOS days
Inpatient Admissions 2,200
Observation Stays 1,100
ED Visits 12,000
Surgeries 3,400
GI Procedures 2,600
Case Mix Index (reflects acuity)

44. C diff Lab ID Rate (new baseline)

45. Lab ID Rate

46. Detect
Treat
Prevent

47. Risk Assessment Suspect …Test We do not have a formal process
Suspect bacterial reason
Recent Antibiotic Usage
Recent Hospital Stay
Nursing Home Patient
History of C diff
Suspect …Test
Get an order – Hospitalist 24/7
Laboratory specimen requirements
Over testing????
25% Positive (130 Tests)

48. Testing Performed at ACL Lab – Off site
Turn Around Time – w/in 24 hours
Testing Methodology - Real-time nucleic acid amplification for the detection of the C. difficile toxin B gene (tcdB)
>97% Sensitive >95% Specificity
Sample: Stool must be liquid or soft enough to conform to the shape of the container. ACL REJECTS SAMPLES
Retesting: detects DNA from both viable and nonviable sources, so this assay is not a test of cure
Testing

49. Aurora Treatment Guidelines
Vancomycin is preferred for all hospitalized patients. Metronidazole for outpatients.
If severe or complicated CDI is suspected empiric therapy may be started
Metronidazole added in some cases

50. Prevention Antibiotic Stewardship Environmental Cleaning
Infection Prevention

52. Environmental Cleaning
Right chemicals
Bleach and Quat
Standardized Procedure
Step by step process
Double Cleaning
Curtains changed
Education
Annual Competencies
Learning Connection
Validation
ATP Testing

53. UV Light – Meet “Slim”
Short-wavelength UV light can kill microorganisms, including C. difficile bacteria.
Used at discharge or transfer in all positive C diff room

54. Isolate immediately with testing/suspect
Infection Prevention
Isolate immediately with testing/suspect
Dedicated equipment, bleach wipes available

55. C diff EPIC Flag Charts are flagged with a positive test result
What does it mean?
Charts are flagged with a positive test result
Shows the history
Flag does not disappear at discharge
Alert flag

56. Education
Educating patients and visitors about isolation precautions allows them to fully understand their role in preventing infections.
Expectation that the patient and family are educated on isolation that day.
Isolation Order triggers Education Record in EPIC
Monitor with feedback

57. Hand Hygiene Sinks installed in nursing unit hallway
Quarterly auditing
92% AMCMC goal
System reporting
Reported to Patient Safety Committee and Infection Prevention Committee
Data provided to caregivers
Worried about the 6% not compliant.

58. Bed Pan/Commode Liners
Implemented March 2017
Clinical educator facilitated and coordinated training
Caregivers liked the product
Helps in maintaining a clean environment.

59. Tell the Story Investigate each case Chart review by IP
Notify Nursing Manager/Supervisor
Meet to discuss
Lessons Learned:
Don’t transfer patients to another room, if possible.
Make sure EVS knows …. Signage remains on door after discharge
We failed to recognize symptoms and patient was readmitted with C diff
Let caregivers know – take ownership

60. Thank You Mentors!

61. Q & A Session

62. Sharing of how to create CDI Action Plan.
CDI Action Planning
Sharing of how to create CDI Action Plan.

63. Next Steps…
Develop your Action Plans & send to Jami Erickson
30 day follow up:
Phone call with Improvement Advisor on your action plans and small tests of change
60 day follow up:
Virtual event/call with all hospitals to highlighting hospitals successes.
Wednesday August 16, 2017
12 pm to 1 pm CT
WHA Quality Center (  Calendar of Events (login required)

64. CDI Resources WHA Quality Center MHA Community Page
Archived HIIN Webinars
Discussion Board
CDC Hand Hygiene training - ers/training/index.html
CDI Starter Pack
CDI IAN Page
Antimicrobial Stewardship IAN Page (Aurora Presentation)

65. Contacts Beth Dibbert Improvement Advisor/Quality Director
Shruthi Murali
Improvement Advisor
Jill Hanson
Bobby Redwood
Physician Improvement
Advisor
Nadine Allen
Kelly Court
Chief Quality Officer
DeAnn Richards
Infection Prevention Improvement Advisor

66. Thank You!