a tiered approach to reduce hospital onset c. difficile brian koll, md, facp, fidsa medical director...
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![Page 1: A Tiered Approach to Reduce Hospital Onset C. difficile Brian Koll, MD, FACP, FIDSA Medical Director and Chief Infection Prevention and Control, BIMC](https://reader035.vdocument.in/reader035/viewer/2022062809/56649e675503460f94b62a48/html5/thumbnails/1.jpg)
A Tiered Approach to Reduce Hospital Onset C. difficile
Brian Koll, MD, FACP, FIDSA
Medical Director and Chief
Infection Prevention and Control, BIMC
Professor of Medicine, AECOM
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HO Clostridium difficile (CDI)CMS 10th SOW
0
1
2
3
4
5
6
7
8
9
National SOW NYS SOW
HO CDI Rate Jul - Dec 2012
Jan - Jun 2013
Goal is 10% reduction6
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HO Clostridium difficile (CDI)New York State DOH
7.67.77.87.9
88.18.28.38.48.58.6
2010 2011 2012 2013
HO CDI Rate
7
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HO Clostridium difficile (CDI)10th SOW BIMC
0
2
4
6
8
10
12
14
16
18
BI Petire BI Brooklyn
HO CDI Rate
Jul - Dec 2012
8
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Tiered Approach
1. Hand hygiene2. Contact precautions3. Sign placement4. PPE readily available
and used5. Dedicated rectal
thermometers
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Tiered Approach
6. Patient placement7. Commodes8. Environmental
cleaning protocols9. Chlorhexidine bathing
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Tiered Approach
10. Antibiotic stewardship11. Pharmaceutical
stewardship
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Begins with Leadership
•Accountability
•Link infection prevention with organizational strategy and resources
•Link a culture of safety to outcomes
•Engage and facilitate teamwork
•Goal setting and measuring and assessing effectiveness
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Begins with Those on the Front Line
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Begins with Those on the Front LineOwnership
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Begins with Those on the Front LineOwnership
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Begins with Those on the Front LineOwnership - Nursing
University of Nebraska
1.bathing three days per weekfollowed by
2.daily bathing
followed by
3.four-month washout period returning to standard soap-and-water bathing
16
Infect Control Hosp Epidemiol 2012;33:1094 - 1100
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Begins with Those on the Front LineOwnership - Nursing
30% reduction in HO CDI with three days per week protocol
59% reduction with daily bathing
17
Infect Control Hosp Epidemiol 2012;33:1094 - 1100
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CDI Survey
Antimicrobial Resistance: Scope of the Problem and Key Contributors
Disagree Neither Agree
1. Antibiotic resistance is a problem in this institution.
5% 17% 78%
2. Patient rooms are cleaned according to hospital cleaning protocol once a C. difficile patient has been discharged.
4% 15% 81%
3. Adherence to hand hygiene protocols is excellent at this institution.
26% 20% 54%
4. Adherence to isolation and contact precautions is excellent at this institution.
34% 16% 50%
5. This institution does NOT do enough to control the development of C. difficile. 44% 30% 26%
6. This institution provides adequate staff education regarding C. difficile. 12% 36% 52%
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Antibiotic Stewardship
• Community acquired pneumonia• moxifloxacin vs ceftriaxone-based therapy
• colonization and infection with multidrug-resistant organisms higher in moxifloxacin group
• restriction policies to diminish moxifloxacin use
Goldstein RC, Lalite S, Mildvan D, Perlman DC, Jodlowski T,Ruhe J. IDSA Poster Presentation 205. Boston, October 2011.
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Antibiotic Stewardship
0
5
10
15
20
25
30
35
40
Feb Mar
Number of
Orders
Moxifloxicin Use
20
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Begins with Those on the Front LineOwnership - Physicians
•San Francisco General
•Jun 2005 – Dec 2010
•historical cohort study
•development of CDI within 30 days of ceftriaxone therapy
•3,730 patients
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Clinical Infectious DiseasesSept 1, 2012 Volume 55 page 615
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Begins with Those on the Front LineOwnership - Physicians
•Multivariate analysis• doxycycline associated with
protection against development of CDI
• 27% lower rate•Hazard ratios ctx + doxy
• vs ctx + azith = 0.15• vs ctx + fluoroquinolone = 0.13
• Stongest predictor of CDI• length of stay
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Clinical Infectious DiseasesSept 1, 2012 Volume 55 page 615
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Antibiotic Stewardship
0
20
40
60
80
100
120
Nov Dec Jan Feb Mar
Number of Orders CTX + AZITH
CTX + DOXY
Clinical Infectious DiseasesSept 1, 2012 Volume 55 page 615 23
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Proton Pump Inhibitors• elderly• underlying medical conditions• broad spectrum antibiotics• PPI
• 28 observational studies• strength of association ranged from 1.4 to 2.8x higher
• Indications• erosive gastritis• symptomatic GERD• NSAID gastric ulcer risk reduction• H. pylori eradication
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Proton Pump Inhibitors
25
0
500
1000
1500
2000
2500
3000
Dec Jan Feb Mar
Number of Units
Nexium
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HO CDI
26
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HO Clostridium difficile (CDI)10th SOW BIMC
0
2
4
6
8
10
12
14
16
18
BI Petire BI Brooklyn
HO CDI RateJul - Dec 2012
Jan - Jun 2013
27
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Value Analysis
On the CUSP Calculator
▶CDI Cases
▶Increased Length of Stay
▶Mortality
▶Median Excess Costs
▶Savings Based on Percent Reduction
– Range $329,640 - $849,756
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Tiered Approach
1. Successful2. Involvement at all
levels of the organization
3. Sustainable results4. Assure continued
improvement
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The Team
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