KPNC Journey in the Fight Against C difficile Infection

Cristine Lacerna, RN, MPH, CIC Nancy Corbett, RN, MHA, CPHRM Paula Grant, RN,BSN, CIC

NCAL Risk And Patient Safety

Learning Objectives

Share the highs, the lows, and the pearls

KP Santa Clara Medical Center's experience

Discuss the various facets in the prevention of hospital associated C. difficile infection

CONFIDENTIAL. For internal use only.

The C. difficile Risk 14,000 deaths in the US each year. Infections are connected with receiving medical care. Almost half of infections occur in people younger than 65 more than 90% of deaths occur in people 65 and older. About 25% of C. difficile infections first show symptoms in hospital

patients; 75% first show in nursing home patients or in people recently cared

for in doctors' offices and clinics.

A National Health Threat

Deaths Caused by C. difficile Infections*

* Age-adjusted Rate of C. difficile as the Primary (Underlying) Cause of Death.

Source: CDC National Center for Health Statistics, 2012

5 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only

June 12, 2014

Identification of the problem

I think I know why you have a headache, but I want to order some additional tests just to make sure…….

What do we know? – The hospital rooms occupied by symptomatic

patients were contaminated 49% of time – Rooms of asymptomatic patients were

contaminated 29% of time – C. difficile inoculated to floor stayed there 5

months – For patients with C. difficile + roommates, time to

acquisition was 3 days vs. 19 days – Of the hospital personnel caring for patients with

positive cultures, 59 percent had positive cultures for C. difficile from their hands

McFarland et al. NEJM. 1989; 320:204 210 --did daily c diff cultures on 428 hospital patients.

Room cleaning

Isolation

Hand Hygiene

Environmental Contamination Room contamination

– 49% rate if symptomatic C. difficile infection (CDI) v. 29% rate asymptomatic colonization

– Placement in a room w/a prior CDI occupant – More recent studies: Contamination rates vary between

2.5%-75% – Rooms occupied by non-infected/colonized patients may be

contaminated Environmental Survival

– Vegetative form 15 minutes - 6 hours – Spore up to 5 months

Reduce HA CDI

Reduce Transmission

Reduce Risk of Disease

Room & equipment Cleaning

Isolation

Reduce Unnecessary

ABX

Reduce Unnecessary

PPIs

Hand Hygiene

Affect All

HAIs

Driver of HA-PNA and CDI

What We Need to Do What needs to happen?

The Line was Drawn…

Northern California Kaiser C. difficile rates mirror that of the national trend since 2008

21 Medical Centers Variations across the

enterprise – THE challenge

CONFIDENTIAL. For internal use only.

The Line was Drawn…

Aug 2009 Expert panels to brainstorm on course of action ID, IP, Leaders, PCS, EVS, Pharmacist

April 2010 KPNC Regional C. difficile reduction summit Kick off message by Regional President on target and

expectation Lay out the case for reduction Introduction of RIGHT bundle & measures

CONFIDENTIAL. For internal use only.

Ground Work

Dec 2010 Vital Behaviors for Hand Hygiene video created by Senior

Leaders

Jan 2011 Provided education to nursing leaders on hand hygiene vital

behaviors and the RIGHT bundle

April 2011 Began hand hygiene secret shopper audits Development of standardized workflows

April 2012 Deliberate Practice workshops

CONFIDENTIAL. For internal use only.

Standardize

CONFIDENTIAL. For internal use only.

Standardize

How do we know we are cleaning the right

way?

How will we ensure all staff

have the right skill set and

knowledge?

How will we know we’re

cleaning effectively?

Developed Regional cleaning policies for the

core patient areas

Implement use of monitoring tools to audit

for effectiveness of cleaning

Train all EVS staff to 7-Step Cleaning

Procedure & Regional cleaning policies

CONFIDENTIAL. For internal use only.

Standardize

Antimicrobial Stewardship –Pharmacist & ID

physician Surveillance of targeted

antimicrobials Rounding with ID

physician

C difficile Prevention Bundle

R Risk Reduction

Isolation

Glove and Gown Etiquette

Hand Hygiene

Touch – Moveable Equipment Cleaning

I

G

H

T

Isolate at first sign infection

Contact Plus; Dedicated Equipment; PPE supplies; Isolate until discharge

Gel before, soap after gloves; Educate patient and family

Clean moveable equipment with bleach after each use

Gel in, soap out; Remind each other, Response: Thank you

HEROES GOES CSI

Controlling the Spread of Infection

Medical Center Self Audits

Was this true?

Secret Shopper Audits Started

Secret Shopper Audits Regional Team audit 21 Medical Centers

quarterly Wide variation in practices within and across

medical centers Few had hardwired appropriate practices Gloves applied without prior hand hygiene High glove use in and out of rooms Hand hygiene coming out of the room more reliable

than going into the room PPE was not always use or used properly

Work flows development began

Standardized Work Flows

After 5,000+ observations Developed based on observed reliable practices Tested and approved by content experts and pilot sites Continue to learn with wide spread implementation Recognized as best practice across organization

Standardized Work Flows

Glove Etiquette Donning and removal of PPE Contact PLUS patient Transport Meal Tray Distribution Patient Ambulation Medication Administration Finger Stick Blood Glucose Cleaning Occupied Room Laboratory Blood Draw Radiology (at bedside)

Deliberate Practice

Practice Practice Practice

CONFIDENTIAL. For internal use only.

No Shortcut to Becoming an Expert

Current Frame

Deliberate Practice

10,000 hour rule

Expert Performance

420 Representatives from 21 Medical Centers

Nurses 163 Nursing Managers 25 EVS 46 Physicians 24 Infection Prevention 23 PCT/Transporter 19 Laboratory 17 Educators 16 Radiology 12 Non-Nursing Managers 11

Resp Therapy 11 Physical Therapy 9 Dietary 9 Quality/Risk Dept 8 Directors 7 ED 3 Pharmacy 1 Social Worker 1 Other 14

CONFIDENTIAL. For internal use only.

Deliberate Practice Stations Speaking Up with Greg and Robbie – Vital behaviors for

hand hygiene Holey Glow – Hand Hygiene and Glove Etiquette We Got You Covered – Proper application and removal

of PPE What the Bleach? – Cleaning moveable equipment Out and About – Transport of C diff patient Not Just a Maid Service – EVS cleaning The Wow of the Wows – Medication administration and

cleaning of moveable computer and scanner All Stuck Up – Lab draws

Vital Behaviors for Hand Hygiene – Gel In-Wash-Out Notice and Speak Up

CONFIDENTIAL. For internal use only.

CONFIDENTIAL. For internal use only.

PPE – Gown and Gloves

The Power of One

CONFIDENTIAL. For internal use only.

Rolling 12 Month HA-CDI Rate per 1000 Admits through April 2013

CONFIDENTIAL. For internal use only.

Reg HA-CDI Summit

(Apr 2010) Secret Shopper Audits

(Apr 2011) Deliberate Practice

Workshops (Apr 2012)

↓ 54% in 3 years

From 150 to 50 A C. difficile Journey

Paula Grant ,RN, BSN, CIC Kaiser Permanente Santa Clara Medical Center

California’s Silicon Valley hospital provides quality care for 300,000 members Facility features a medical office building and 327 bed acute care hospital More than 700 physicians and 4,300 staff

31 | © Kaiser Permanente 2010-2011. All Rights Reserved. June 12, 2014

In 2010 we started this journey

WE HAD A VISION

The 2010 C. difficile SUMMIT: Reduce transmission Reduce the burden

Provide clarity about what to do Provide a structured & safe environment to make

changes in care delivery

Determined to Be Different

1110 infections

Reduce C diff

infections by one third by July 1, 2011

Reduce C diff by half by July 1, 2012

C difficile Prevention Bundle

Risk Reduction

Isolation

Glove and Gown Etiquette

Hand Hygiene

Touch – Moveable Equipment Cleaning

R

I

G

H

T

Isolate at first sign of infection

Contact Plus; Dedicated Equipment; PPE supplies

Gown & glove in room, EVERYTIME!

Clean moveable equipment with bleach before removal from CDI room

“Foam in, Soap out”; Social Movement

Share the Vision

• Created definitions for Hospital and Community

associated C. difficile disease • Established benchmark for the year

• Monthly C. difficile dashboard with number of cases, rates, dedicated equipment isolation results shared

with leadership and frontline staff • Quality Performance Improvement nurses rounding

daily reviewing precautions

• Infection Preventionists providing data and updates weekly to leadership

• C.difficile algorithm as a guideline for isolation precautions

• Antibiotic stewardship rounds seven days a week by the pharmacist and ID

• Multidisciplinary drill down with-front line staff • The findings and learnings from all cases are given to

managers to present at the Healthcare Associated Infections Committee

Share the Vision

Smooth the Bumps in the Road

Bright yellow isolation PPE caddies on the patient room door for ease of use, removable floor “Stop” sign decals

EVS staff education, return demonstration competency validation and simulations

EVS performing ATP testing on “Contact Plus” discharge rooms Mobile equipment cleaning and disinfection with bleach Emergency Department partnership with initiating “Contact

Plus” precautions

CONTACT PLUS Precautions

CONTACT PLUS Signage • Floor “STOP” sign decal Yellow Caddy

– Filled with gowns, gloves

Isolation Caddy

Gowns

Gloves

• Hangs on patient room door •Contact •Contact Plus •Droplet

• Place Isolation Sign on patient door frame

• Ensure that PPE’s are sufficiently stocked with gloves, gowns and masks

• Wipe caddy down with SaniCloth AF3® after patient is discharged

• Leave isolation sign up so EVS is aware of room status

STOP sign floor decals are used for Contact Plus isolation rooms Clean floor decals after

removal from the floor with SaniCloth AF3

Isolation STOP Sign

ISOLATION

Workflow Improvements Send off 1st loose stool (either in ED or inpt unit) Educate PCTs:

– Collecting loose stools – Communication with the RNs regarding loose stool

Improved RN and physician communication – ICU discusses patient bowel habits in multidisciplinary rounds – Educated RN to place patient on precautions until physicians

are able to assess situation

IP sends a daily list of isolation patients to Quality PI RNs and EVS

The Journey…. So far

48

2013 Lawrence Patient Safety Award

Awarded to four Northern California Kaiser Hospitals for its Reduction of Hospital Acquired Clostridium difficile Infection (HA-CDI) program Standardized practices reduced HA-CDI and also

reduced other hospital acquired infections and multi-drug resistant organisms

The Destination (we’re not there yet)

Key strategies

– Communication – Antibiotic Stewardship

– EVS cleaning and disinfection process

– Hand Hygiene Performance Improvement Program

– FLU vaccine to employees and members

Anchor a New Approach

We know what works and what doesn’t

What can we let go of safely and where can we add new methods?

Video

2013 Lawrence Patient Safety Award. Video

Questions? Paula Grant RN, BSN, CIC,

-- Paula.Grant@kp.org