1. 1 1 Quality Forum 2013 February 28, 2013 Vancouver, B.C. Ivy Chow, Pharmacist Jan Chan, Registered Dietitian Judi Moscovitch, Quality Improvement & Patient Safety Evidence-based Care for the CDI patient Burnaby Hospital

2. 2 2 Disclosure We are unable to identify any potential conflict of interest and have nothing to disclose EXCEPT A strong bias towards ensuring quality, safe care delivery to our patients.

3. 3 3 Key Objectives A. Demographics B. Care and Management C. Recommendations

4. 4 4 HSMR Factor 724 CDI Cases Q1 2009 – Q3 2011/12 Age Over 80 60.8% Gender Female 51.8% Urgent admit EHS 97.2% Transfer in Residential 17.5% LOS 22 – 365 days 59.5% Comorbidities Cardiovascular 89.0% A. Demographics

5. 5 5 B. Care and Management RN review of 82 patient charts Pharmacy review of 65/82 charts Understand the Patient Journey

6. 6 6 Antibiotic Usage 98.5% of patients were on antibiotics 90 days prior to testing positive for C difficile. Safety 30.8% of patients had an opportunity for a prescription or process change.

7. 7 7 Antibiotic Practices

8. 8 8 Prevention 26.2% of patients who were on Proton Pump Inhibitors had an opportunity for prescription change. Effectiveness and Safety

9. 9 9 What can we do?  Reduce the use of inappropriate antibiotics  Review the need for Proton Pump Inhibitors  Refer patients to Pharmacy for medication review Medication Management

10. 10 Probiotics (Saccharomyces Boulardii)  Pharmacy and Nutrition literature indicates that Probiotics are not useful after diagnosis of CDI.  Some literature supports the use of probiotics for prevention of antibiotic-associated diarrhoea. 41 patients or 64.1% were prescribed Probiotics after CDI Diagnosis. Effectiveness, Efficiency and Safety

11. 11 Probiotics  Saccharomyces Boulardii is contra- indicated for immuno-compromised patients.  Of the 17 immuno-compromised patients in this study, 52.9% received Saccharomyces Boulardii. Effectiveness and Safety

12. 12 What can we do?  Review medical literature prior to prescribing Saccharomyces Boulardii when:  Patient has active CDI  Patient is immuno-compromised  Patient is in Critical Care Unit Medication Management

13. 13 CDI Diarrhoea  Secretory diarrhoea  Bowel rest (not eating) does not stop the diarrhoea  Increases active secretion >>> Protein loss >>> Increased risk of malnutrition Effectiveness and Safety

14. 14 CDI and Diets NO literature to support diets that are:  Lactose free  Fibre free or Low fibre including formulas  Pre-digested (elemental) >>>Don’t limit intake Effectiveness and Safety

15. 15 Diet Recommendation Unless patient shows signs of Ileus, colonic perforation, Toxic Megacolon or fulminant type of C.difficile NPO Or Hold Tube Feeds

16. 16 Nutrition & Hydration

17. 17 What can we do?  Refer malnourished patients to Dietitian  Educate the care team regarding appropriate diets for CDI pts. AND Remind and/or assist patients to wash their hands before eating Nutrition Care and Management

18. 18 Management of Nutrition & Hydration Effectiveness

19. 19 Effectiveness and Safety Nursing Management  Doing well: Bristol Stool Chart  Opportunity for Improvement:  Monitoring of indicators  Documentation of nutrition & hydration  Implementation of CDI Checklist

20. 20 What can we do?  Implement a standardized approach to Manage Nutrition and Hydration  Standardize and implement process for monitoring, treating and documenting CDI care. Nursing Care and Management

21. 21 Effectiveness and Safety Interventions  55.4% prescriptions for CDI deviated from recommended guidelines  No comprehensive care pathway for patients not responding

22. 22 “CDI should be managed as a diagnosis in its own right, with each patient reviewed daily regarding fluid resuscitation, electrolyte replacement and nutrition review. Monitor for signs of increasing severity of disease, with early referral to ITU as patients may deteriorate very rapidly.” Core Guidance 3.6 Clostridium difficile infection: How to deal with the problem Department of Health, UK

23. 23 What can we do?  Implement Pre-Printed Orders for CDI treatment  Review each case regularly for response to interventions Disease Management

24. 24 We can work as an integrated, comprehensive Health Care TEAM!  Physician  Nurses and Aides  Dietitian  Pharmacist  Infection Control  Housekeeping  Laundry Services Who else is on your TEAM? Effectiveness and Safety

25. 25 1.Manage Medications  Review Antibiotics, PPIs and use of Probiotics 2.Manage Nutrition and Hydration  Review and individualize plan  Monitor intake and output 3.Manage the CDI disease process  Pre-Printed Orders  A Standardized Care Pathway  Consistent monitoring  Weekly case review  Integrated Team approach C. Recommendations Care & Management Bundle

26. 26 C. Recommendations Care & Management Bundle Don’t Forget! 4. Patient and Family Engagement  Patient hand-washing prior to eating  Follow Contact Plus precautions

27. 27 Where to Start www.dh.gov.uk www.ihi.org www.saferhealthcarenow.ca

28. 28 For more information please contact: Jan Chan, Dietitian Practice Leader jan.chan@fraserhealth.ca jan.chan@fraserhealth.ca Ivy Chow, Pharmacist ivy.chow@fraserhealth.ca Judi Moscovitch, Consultant, Quality Improvement & Patient Safety judi.moscovitch@ judi.moscovitch@ fraserhealth.ca What change can you make to drive QUALITY CDI care?