b3 judi moscovitch - evidence-based care for cdi patients
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Quality Forum 2013February 28, 2013
Vancouver, B.C.
Ivy Chow, Pharmacist Jan Chan, Registered Dietitian
Judi Moscovitch, Quality Improvement & Patient Safety
Evidence-based Care
for the CDI patientBurnaby Hospital
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Disclosure
We are unable to identify any potentialconflict of interest and have
nothing to disclose
EXCEPTA strong bias towards ensuring quality,
safe care delivery to our patients.
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Key Objectives
A. DemographicsB. Care and ManagementC. Recommendations
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HSMR Factor 724 CDI CasesQ1 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
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B. Care and Management
RN review of 82 patient chartsPharmacy review of 65/82 charts
Un
ders
tan
d t
he P
ati
en
t Jo
urn
ey
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Antibiotic Usage
98.5% of patientswere on antibiotics
90 days prior totesting positive
for C difficile.
Safe
ty
30.8% of patients had an opportunity for a prescription or process change.
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BH CDI Pharmacy Study May 2012
80%
90%
100%Don't Tx Asymptomatic Bacteriuria
De-escalate Tx ASAP
Appropriate Empiric Choice
Appropriate Shortest Duration
Change/Remove Foley Catheter
Order cultures first
Antibiotic Practices
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Prevention
26.2% of patients
who were on Proton Pump
Inhibitors had an
opportunity for prescription
change.
Eff
ect
iveness
and S
afe
ty
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What can we do?
Reduce the use of inappropriate antibiotics
Review the need for Proton Pump Inhibitors
Refer patients to Pharmacy for medication review
Med
icati
on
Man
ag
em
en
t
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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.
Eff
ect
iveness
, E
ffici
ency
an
d
Safe
ty
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Probiotics
Saccharomyces Boulardii is contra-indicated for immuno-compromised patients.
Of the 17 immuno-compromised patients in this study, 52.9% received Saccharomyces Boulardii.
Eff
ect
iveness
and S
afe
ty
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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
Med
icati
on
Man
ag
em
en
t
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CDI Diarrhoea
Secretory diarrhoea Bowel rest (not eating) does not
stop the diarrhoea Increases active secretion>>> Protein loss >>> Increased risk of malnutrition
Eff
ect
iveness
and S
afe
ty
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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
Eff
ect
iveness
and S
afe
ty
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Diet Recommendation
Unless patient shows signs of Ileus, colonic perforation,
Toxic Megacolon or fulminant type of C.difficile
NPOOr Hold Tube Feeds
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BH CDI Chart Review May 2012
0%
20%
40%
60%
80%
100%Dietitian Consult
Appropriately Nourished
Avg. > 50% intake daily
Diet Changed due to CDI
Nutrition & Hydration
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What can we do?
Refer malnourished patients to Dietitian
Educate the care team regarding appropriate diets for CDI pts.
ANDRemind and/or assist patients to
washtheir hands before eating
Nu
trit
ion
Care
an
d M
an
ag
em
en
t
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Management of Nutrition & Hydration
Eff
ect
iveness
BH CDI Chart Review May 2012
0%
20%
40%
60%
80%
100%
Weighed on Admission
Weighed when Diarrhea Started
% Meals Eaten Documented
In/Out Monitoring StartedIn/Out Monitoring Totalled
CDI Checklist
Bristol Chart initiated
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Eff
ect
iveness
and S
afe
ty Nursing Management
Doing well: Bristol Stool Chart Opportunity for Improvement:
Monitoring of indicators Documentation of nutrition & hydration Implementation of CDI Checklist
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What can we do?
Implement a standardized approach to Manage Nutrition and Hydration
Standardize and implement process for monitoring, treating and documenting CDI care.
Nu
rsin
g C
are
an
d M
an
ag
em
en
t
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Eff
ect
iveness
and S
afe
ty Interventions
55.4% prescriptions for CDI deviated from recommended
guidelines No comprehensive care pathway for patients not responding
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“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
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What can we do?
Implement Pre-Printed Orders for CDI treatment Review each case regularly for response to interventions
Dis
ease M
an
ag
em
en
t
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We canwork as an integrated,
comprehensive Health Care TEAM!
Physician Nurses and Aides Dietitian Pharmacist Infection Control Housekeeping Laundry Services
Who else is on your TEAM?Eff
ect
iveness
and S
afe
ty
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1. Manage Medications Review Antibiotics, PPIs and use of
Probiotics2. 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. RecommendationsCare & Management
Bundle
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C. RecommendationsCare & Management
Bundle
Don’t Forget!
4. Patient and Family Engagement
Patient hand-washing prior to eating
Follow Contact Plus precautions
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Where to Start
www.dh.gov.uk
www.ihi.org
www.saferhealthcarenow.ca
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For more information
please contact:
Jan Chan, Dietitian Practice Leader
jan.chan@fraserhealth.ca
Ivy Chow, Pharmacist
ivy.chow@fraserhealth.ca
Judi Moscovitch, Consultant,
Quality Improvement & Patient Safety
judi.moscovitch@fraserhealth.ca
What changecan you make
to drive QUALITY CDI care?
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