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KPNC Journey in the fight against C difficile infection

Learning ObjectivesShare the highs, the lows, and the pearlsKP Fresno Medical Center's experienceDiscuss the various facets in the prevention of hospital acquired C diff infectionCONFIDENTIAL. For internal use only.The ProblemNationally hospital stays associated with CDI has been increasing since 1993 (Source: AHRQ)KP Northern California saw similar trend with a spike in 200821 Medical Centers and numerous associated Medical Office Building

CONFIDENTIAL. For internal use only.The line was drawnAug 2009Expert panels to brainstorm on course of actionID, IP, Leaders, PCS, EVS, PharmacistApril 2010KPNC Regional C diff reduction summitKick off message by Regional President on target and expectationLay out the case for reductionIntroduction of RIGHT bundle & measures

CONFIDENTIAL. For internal use only.Ground workDec 2010Vital Behaviors for Hand Hygiene video created by Senior LeadersJan 2011Provided education to nursing leaders on HH vital behaviors and the RIGHT bundleApril 2011Began HH secret shopper auditsDevelopment of standardized workflowsApril 2012Deliberate Practice workshopsCONFIDENTIAL. For internal use only.StandardizeCONFIDENTIAL. For internal use only.

StandardizeHow do we know were cleaning the right way?How will we ensure all staff have the right skill set and knowledge?How will we know were cleaning effectively?

Developed Regional cleaning policies for the core patient areasImplement 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.The EVS aides received training based on standardized regional policies and procedures. Additionally, new technology were utilized to assess the efficacy of the cleaning by using ATP. An ATP machine is a testing device that measures surface contaminants in the form of ATP (adenosine triphospate a biochemical produced by most organisms a high level of ATP (> 200) after cleaning means the cleaning was not effective.7StandardizeAntimicrobial StewardshipPharmacist & ID physicianSurveillance of targeted antimicrobialsRounding with ID physician

Stephen

The ChallengeHow do we know a change is an improvement?

CONFIDENTIAL. For internal use only.The RIGHT BundleRisk Reduction Isolate at first sign of infectionIsolation Contact Plus, Dedicated equipment, isolate until dischargeGlove & Gown Etiquette Gel before and soap after gloves educate patient and familyHand Hygiene Gel in, soap out; Remind each other, Response: Thank youTouch Moveable Equipment Cleaning Clean moveable equipment with disinfectant between pts use and bleach before exiting Contact PlusCONFIDENTIAL. For internal use only.Secret Shopper AuditsRegional Team audit 21 Medical Centers quarterlyWide variation in practices within and across medical centersFew had hardwired appropriate practices Gloves applied without prior hand hygieneHigh glove use in and out of roomsHand hygiene coming out of the room more reliable than going into the roomPPE was not always use or used properlyWork flows development beganStandardized Work FlowsAfter 5,000+ observationsDeveloped based on observed reliable practicesTested and approved by content experts and pilot sitesContinue to learn with wide spread implementationRecognized as best practice across organization

Standardized Work FlowsGlove Etiquette Donning and removal of PPE Contact PLUS patient TransportMeal Tray Distribution Patient AmbulationMedication AdministrationFinger Stick Blood GlucoseCleaning Occupied RoomLaboratory Blood DrawRadiology (at bedside)Deliberate PracticePracticePracticePracticeCONFIDENTIAL. For internal use only.No Shortcut to Becoming an Expert

CurrentFrameDeliberate Practice10,000 hour ruleExpertPerformance 420 Representatives from 21 Medical CentersNurses 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 11Physical Therapy 9Dietary 9Quality/Risk Dept 8Directors 7ED 3Pharmacy 1Social Worker 1Other 14CONFIDENTIAL. For internal use only.Deliberate Practice StationsSpeaking Up with Greg and Robbie Vital behaviors for hand hygieneHoley Glow Hand Hygiene and Glove EtiquetteWe Got You Covered Proper application and removal of PPEWhat the Bleach? Cleaning moveable equipmentOut and About Transport of C diff patientNot 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

Nancy, please choose and insert work flows, videos, etc.CONFIDENTIAL. For internal use only.Rolling 12 Month HA-CDI Rate per 1000 Admits through April 2013CONFIDENTIAL. For internal use only.

Reg HA-CDI Summit (Apr 2010)Secret ShopperAudits (Apr 2011)Deliberate Practice Workshops(Apr 2012) 54% in 3 yearsFresno Team insert slidesCONFIDENTIAL. For internal use only.Clostridium DifficileKaiser Foundation Hospital, Fresno Infection Prevention & Control Risk Priority

C Difficile PreventionRisk Reduction Hand HygieneCleaning (Environment & Equipment) Antibiotic Stewardship Education2222Pancy end this slide by 1:35Clostridium Difficile was identified as the top priority for the Fresno Medical Center in November 2009 by the Infection Control Committee. Recognized as a priority every year since. A multidisciplinary work group was initiated to begin the work and risk mitigation efforts. The work group efforts was aligned with the regional HEROES (CSI) Group. Increase in the work groups multidisciplinary scope to include a wider range of departments.

Risk Reduction Risk Reduction Collect specimen with the first diarrhea episode Initiate CONTACT PLUS precautions Call physician for lab order. Place hat in toilet for all new admissions

Alert other departments when patient has procedures done outside of room (i.e. Radiology)

Dedicated equipment only: (disposable B/P cuff, Stethoscope, Thermometer, O2 sat probe) WANDA & other equipment the patient may require

Provide commodes for ER patients with diarrhea and ease of specimen collection2424Pancy

Dedicated Equipment

2525PancyCONTACT PLUS Precautions Dedicated EquipmentBlood pressure cuff, thermometer & stethoscopeMobile computer carts should be placed in the isolation room and not removed for the duration of the isolationConsider walker, gait belt, and Arjo lift

The Hands Give It Away

Hand Hygiene

Complete medical center Degermer assessment was under taken in 2010, reassessment in 2012. Hand Hygiene HeroSecret ShoppersFrontline staff engagement and empowermentThree vital behaviorsCHAMPS

OFFICES

ED ASSESSMENT14QUIK-CARE ALREADY IN PLACE

9ADDITIONAL TO BE PLACED

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3 EAST ASSESSMENT12QUIK-CARE ALREADY IN PLACE

8ADDITIONAL TO BE PLACED

30

3 WEST ASSESSMENTQUIK-CARE ALREADY IN PLACE

ADDITIONAL TO BE PLACED

1311

31

ADDITIONAL TO BE PLACED

7QUIK-CARE ALREADY IN PLACE

144 EAST ASSESSMENT

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4 WEST ASSESSMENTADDITIONAL TO BE PLACED

QUIK-CARE ALREADY IN PLACE

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33Hand Hygiene Task Force2010 Alcohol Degermer Final AssessmentCCU Department No Additional Alcohol Degermer Mounting Required Free Standing Quik-Care Foam Canisters Placed in Every Room83QUIK-CARE CURRENTLY IN PLACE47ADDITIONAL PROPOSED PLACEMENT

50 ACTUAL PLACED342012 Alcohol Degermer Final AssessmentLabor and Delivery / Postpartum Free Standing Quik-Care Foam Canisters Placed in Every Room143QUIK-CARE CURRENTLY IN PLACE22ADDITIONAL PROPOSED PLACEMENT

22 ACTUAL PLACED3536Three Vital BehaviorsGel in / Gel Out Notice & Speak UpSay Thank YouGel in before you enter a patients roomGel out when leaving a patients roomUse soap and water for Contact Plus patientsYou see a co-worker forget to wash their handsRemind them to wash their handsSay thank you and wash up if someone reminds you to wash your hands

36PASSING MEAL TRAYSWash hands for 20 seconds before preparing traysPatient not in IsolationGel/foam handsPickup tray ticket and take into patients roomCheck 2 patient identifiersCorrect patient then pick up tray from cart and take into patients room.Remove PHI from tray ticket and place in trash bag taped to cartGel/foam hands when leaving room and before entering next patients roomContact or Contact Plus Isolation roomCart used, tape small trash bag on side of cartReturn to Cart without leaving patients roomPick up tray and take tray into patients roomRemove PHI from tray ticket and place in trash bag taped to cartUpon exiting the patients room for Contact Plus Isolation, immediately wash hands with soap and water for 20 secondsFor Contact Isolation, gel/foam hands on exitCart used, tape small trash bag on side of cart10/2013If the cart is pushed or cart handles touched, gel/foam hands again before taking tray into the room.Gel/foam hands on exit from roomGel/foam hands , put on PPE as required including gown and glovesRepeat for each patientRequires a disposable trayPick up tray ticket and enter patients roomCheck 2 patient identifiersRemove PPE before leaving patients room, place in trash in roomRepeat for each patientAt end of Meal Service dispose of PHI bag in secured PHI container Note cart is used for serving meal trays.37ASSISTING OUT OF THE ROOM AMBULATION FOR A PATIENT ON CONTACT OR CONTACT PLUS ISOLATIONPerform hand hygiene (gel in) and put on gown and glovesIf an assistive device is needed, clean with bleach wipe before and after use. (Must be allowed to dry before touching.)Assist patient to bed or chairWhen ready to leave room, remove gown and gloves and wash handsReturn patient to room10/2013If patient is unsteady on their feet, collaborate with a second patient care staff member to provide assistance to the patient at the door.When ready to leave room, remove gown and gloves and wash hands. Ambulation should be limited to patients unit. Exceptions should be approved through Infection Prevention and ControlThe patient is not allowed to visit other patients, ambulate into kitchen/pantry on the unit, into the cafeteria, gift shop, or waiting rooms2 staff members may be needed: one to assist the patient in the room before and after ambulation and the second to provide assistance while ambulating.Verify that the following steps have been completed with the patients nurse.Prior to ambulating out of the room, the patient must:Have diarrhea contained or be continent of stool (i.e. diaper, rectal tube, rectal bag, etc.)Have a bath or showerHave a complete linen changeHave drains/drainage bags emptiedHave drains secured to gownPut on a clean gownWash their hands with soap and water for 15 secondsPPE is used per Standard Precautions(contact with blood, body fluids, non-intact skin)If patient is unsteady on their feet, collaborate with a second patient care staff member to provide assistance to the patient at the door.Perform hand hygiene (gel in) and put on gown and glovesNo gowns and gloves required when ambulating unless used per Standard Precautions.Checklist must be completed prior to ambulating patient outside of room.ASSISTING OUT OF THE ROOM AMBULATION FOR A PATIENT ON CONTACT OR CONTACT PLUS ISOLATIONPerform hand hygiene (gel in) and put on gown and glovesIf an assistive device is needed, clean with bleach wipe before and after use. (Must be allowed to dry before touching.)Assist patient to bed or chairWhen ready to leave room, remove gown and gloves and wash handsReturn patient to room10/2013If patient is unsteady on their feet, collaborate with a second patient care staff member to provide assistance to the patient at the door.When ready to leave room, remove gown and gloves and wash hands. Ambulation should be limited to patients unit. Exceptions should be approved through Infection Prevention and ControlThe patient is not allowed to visit other patients, ambulate into kitchen/pantry on the unit, into the cafeteria, gift shop, or waiting rooms2 staff members may be needed: one to assist the patient in the room before and after ambulation and the second to provide assistance while ambulating.Verify that the following steps have been completed with the patients nurse.Prior to ambulating out of the room, the patient must:Have diarrhea contained or be continent of stool (i.e. diaper, rectal tube, rectal bag, etc.)Have a bath or showerHave a complete linen changeHave drains/drainage bags emptiedHave drains secured to gownPut on a clean gownWash their hands with soap and water for 15 secondsPPE is used per Standard Precautions(contact with blood, body fluids, non-intact skin)If patient is unsteady on their feet, collaborate with a second patient care staff member to provide assistance to the patient at the door.Perform hand hygiene (gel in) and put on gown and glovesNo gowns and gloves required when ambulating unless used per Standard Precautions.Checklist must be completed prior to ambulating patient outside of room. Hand HygieneCONFIDENTIAL. For internal use only. Hand Hygiene Hero

Secret Shoppers

Frontline staff engagement and empowermentCHAMPS (Clean Hands Are Making Patients Safer)Positive reinforcement by calling out when you observe someone washing their hands

Observe each other

Post results in all patient unit areas for staff to track their progressCONFIDENTIAL. For internal use only.The Environmental Service Department implemented extensive training in effective room cleaning with the use of Sodium Hypochlorite.

The cleaning is validated by the use of Adenosine Triphosphate (ATP) meter which measures the relative light units (RLUs) of the 14 High Frequently Touched Surfaces.

The system indicates overall biological contamination including microbiological and product residues. This approach has been instrumental in reducing the microbial load on the highly touched surfaces around the patients room.

Cleaning (Environment & Equipment )Bleach only for cleaning throughout the facility

ATP random testing on clean rooms

Pilot for disposable curtains with embedded antimicrobials - now used in most patient care areas

Alert EVS when patient is transferred between rooms or discharged and CONTACT PLUS precautions in place.

Touch It, Clean It: Moveable Equipment

4444LisaShared patient care equipment must be disinfected between patients per manufacturers recommendation or use bleach wipes if there is no recommendation

Exampes areIV poles, diamap, pulse toiletry probe, ultrasound machine, keyboard and mouse, walkers, gurneys

Follow medical facility policy on reprocessing of instruments and devices

Jan-Sep, 2010:301 patients followed; 33 with positive C. difficile culture200 Pharmacist recommendations made with 93% acceptance rate by physicians.2012:ID physician provided intense education to a select group of pharmacists and continues to meet with them monthly and as needed

Antibiotic StewardshipIntense Drill Down of every Hospital Associated Clostridium Difficile Infection

What happened? Why it happened?Could we have prevented it? What can we do to make sure it doesnt happen in the future?

EducationAnnual SkillsAdvocates on all units around the clock serve as a resource to our front line staff in their daily work flow.Specimen collection items placed in every new admissions bathroomDaily briefing to review every isolation patient and every specimen needed for collectionStool Characteristics ReportEscalation process for specimen collection

EducationCONFIDENTIAL. For internal use only.

Stool Characteristics ReportC. difficile is More Prevalent in the Community than in the HospitalCommunity Acquired Clostridium difficile Infection is More Common Than Hospital-Onset in Hospitalized Patients A Two-Year Retrospective StudyHarold Lin, MD; Raed Khoury, MA, MPH; Thomas Lam, MD; Kurt Hishida, RN; Krickett Pal, RN; Elisa Porter, BA; Dee Lacy, MD Infectious Diseases and Infection Prevention TeamBackground:Hospital-Onset Clostridium difficile Infections (HO-CDI) are a major focus for infection prevention in the United States. Little data exists on the relationship between Community Onset Clostridium difficile Infections (COCDI) and HO-CDI. Preventing Clostridium difficile infection (CDI) in the Community has been overlooked. This study will outline the importance of CO-CDI rates and its impact on the HO-CDI rates.Methods:This was a retrospective study of all 158 CDI patients admitted to Kaiser Permanente Hospital, Fresno, California in 2011 and 2012. CO- CDI was diagnosed when a patient had unexplained diarrhea and a positive stool test for CDI within 72 hours after admission. Patients that were admitted whose stool tested positive but were in the hospital within the previous 4 weeks were defined as Community-onset healthcare-associated CDI (COHA- CDI). In the Initial 4 months of the study (18% of the cases [29 of 158]), we utilized Enzyme Immunoassay (EIA) to detect toxins for diagnosis. For the remaining cases (82% of the cases [129 of 158]),we used EIA to detect Glutamate Dehydrogenase and confirmed toxins by Polymerase Chain Reaction. We also reviewed antibiotics, proton pump inhibitors (PPIs) and H2 Blockers prescribed within 30 prior to CDI forall 158 cases.Results:Out of all patients admitted to the hospital with CDI: 60% (n=95 of 158) were identified as CO-CDI; 23% were HO-CDI; 17% CO-HA-CDI. During the beginning of this study period, 9% (n=14 of 158) of the CDI could havebeen identified as CO-CDI had the testing been timely. The incidence of CO-CDI increased 14% from 2011 (n=45 of 158) to 2012 (n=50 of 158).Among CO-CDI cases, 73% received antibiotics, 32% H2 Blockers, and 25% PPIs within 30 days prior to CDI. For HO-CDI cases, 94% received antibiotics, 58% H2 Blockers, and 44% PPIs. Conclusion:Incidence of CO-CDI in hospital is more significant than generally appreciated. Importance of CO-CDI should not be overlooked in the effort to reduce HO-CDI infections. H2 blockers are more significantly involved in all CO-CDI, HO-CDI and CO-HA-CDI cases compared to PPIs. More research is needed to truly identify the impact of CO-CDI on Hospital Rates and the role of H2 blockers in CDI.50Who is Responsible?

PatientsPhysiciansNursesLeadershipEnvironmental ServicesPatient Care TechsLabRespiratory Therapy NutritionChaplainsvolunteersSocial WorkersVisitors/FamilyPhysical TherapyDischarge PlannersInfection Prevention Our LeadersDo the right thing even when no one is looking

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