using measurement to inform and improve
DESCRIPTION
Maureen Spencer, RN, M.Ed., CIC Infection Control Manager New England Baptist Hospital, Boston, MA. Using Measurement to Inform and Improve. Presentation Objectives. Demonstrate how one hospital used the new CDI surveillance definitions to identify an increase of CDI on one nursing unit. - PowerPoint PPT PresentationTRANSCRIPT
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Maureen Spencer, RN, M.Ed., CICInfection Control Manager
New England Baptist Hospital, Boston, MA
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Presentation Objectives
Demonstrate how one hospital used the new CDI surveillance definitions to identify an increase of CDI on one nursing unit.
Describe enhanced environmental controls to reduce transmission of CDI
Describe the new Clostridium difficile Infection (CDI) Collaborative Definition
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New England Baptist HospitalJune 2008
Received the CDI Surveillance Working Group CDI definitions at the APIC Conference 2008 in Denver
ICP presented the new surveillance definitions to the Infection Control Committee
Reclassified cases in July 2008 Identified one nursing unit with 76% of the
cases of HA-CDI Contributing Factors:
Several of the patients had also been in the ICU and were transferred in an ICU bed rather than stretcher, and often went back and forth between the two units in the same bed
Patients were being removed from Special Contact Precautions after diarrhea stopped, prior to discharge – housekeeping didn’t know the room needed to be cleaned with bleach or cubicle curtains changed
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New Surveillance Definitions
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Initial Investigation August 2008 •FY08 = 24 Patients with positive C.difficile
titers – 3 from outpatient locations –21 from inpatients (87.5%)
•Nursing Unit - Developed Signs and Symptoms: –J4 East 16/21 cases (76%) –L 5 1/21 cases ( 5%) –5 East 3/21 cases (14%) –ICU 1/21 cases ( 5%) 3 of 16 Jenks4East cases were in room 465
- 2 of the CA-CDI (community-acquired) cases were in room 465
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Poster we presented at APIC 2007 showing CDI with room association – 28 patients had been in 42 rooms!
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Month Hosp Onset
Community Onset – HAI
Indeterminate Community-acquired
Total
October 1 2 1 1 5
November 3 1 3 7
December 1 2 0 3
January 1 0 1
February 2 2
March 1 1 1 3
April 0
May 0
June 1 1 2
July 2 2
Aug 1 2 1 4
Sep 2 3 5
Total 13 8 3 10 34
FY2008 - NEBH Cases Per New Definitions
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C.Difficile Team - August 08
Formation of C.Difficile Team: Dr. Camer (Chief of Surgery) Dr. Lui (Chief of Gastroenterology), Sharon Connolly, RN – Nurse Manager, Sue Cohen,MT (ASCP) Microbiology Supervisor, Maureen Spencer, RN, Infection Control Met weekly, reviewed literature, formulated control measures, designed a retrospective case review, and educational offerings
Instituted Use of Chlorox Bleach Wipes Enhanced Education for Staff Changed patient transfer procedure
Stretcher (not in bed) Retrospective Case Review of all CDI cases
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Retrospective Case ReviewFY2008 N=34
Proton pump inhibitors 13 (67%) Cancer 12 (35%) Fluorquinolone use 9 (26%) Obesity 9 (26%) CT Scan before onset 6 (18%) MRSA Colonization 5 (15%) VRE Colonization 3 ( 9%) Diabetes 3 ( 9%)
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Enhanced Prevention Education
Transfers between units on stretchers versus contaminated bed Green tag flagging system for cleaned
equipment
Dinamap baskets with sanicloths and not allowed in precautions rooms
Spatial Separation of precaution cases Bleach wipes for all precaution rooms Enhanced cleaning of equipment
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Nursing Unit Decontamination Decontaminated 19 rooms with dri-mist particle
generator that breaks down disinfectant into microscopic, negatively charged ion particulates.
These particulates are smaller than one micron in diameter and can access ALL surfaces of a room.
Particulates are negatively charged and stick to positively charged contaminants
Some evidence it will kill spores (testing done by VAMC, W. Palm Beach, FL – biological indicators (G. stearothermophilus) placed around the room in areas to being treated – all were negative)
Three day period – lease arrangement with company Cost: ~$5000.00 for 19 rooms Issues: set off smoke detectors, prep time to seal
ventilation and doors
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NEBH CDI Rates FY08-FY10 FY08 FY09 FY10 (Oct-Apr)Total HAI 21 Total HAI 13 Total HAI 7
Patient Days 28914 Patient Days 28382 Patient Days 15967Rate/10,000PtDays 7.3
Rate/10,000PtDays 4.6
Rate/10,000PtDays 4.4
(37% reduction)
Hospital Onset 13 Hospital Onset 10 Hospital Onset 5Rate/10,000PtDays 4.5
Rate/10,000PtDays 3.5
Rate/10,000PtDays 3.1
(22% reduction)
Comm Onset HA 8Comm Onset HA 3 Comm Onset HA 2
Rate/10,000PtDays 2.8
Rate/10,000PtDays 1.1 Rate/PtDays 1.2
(61% reduction)
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Interventions in 2010 Decontamination of the Ambulatory
Care Unit (our “mini-ER”) after observing commode handling procedures and use of community bathroom by CDI patients.
Decontamination will be done in July on the night shift with a vaporized hydrogen peroxide room decontaminator.
Implemented commode liners to eliminate disposal of liquid waste by staff.
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Healthcare Facility Acute Care Hospital
Rehabilitation Facility Nursing Home
Other Chronic Care
A case of C. difficile is defined as a case with diarrhea without other known etiology. The stool sample will yield a positive result for laboratory assay for C. difficile toxin A and/or B (or positive PCR) For purposes of this collaborative, C. difficile is limited to laboratory confirmed cases. This collaborative will track healthcare facility associated C. difficile
C. difficile (CDI) Collaborative Definition
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C. difficile (CDI) Collaborative Definition
A patient classified as having a case of healthcare facility associated C. difficile is defined as a patient who develops diarrhea more than 48 hours after admission
ORA patient classified as having any symptoms that develop within 48 hours after discharge to another healthcare facility.
ORA patient discharged to home with lab confirmed C.diffIcile within 28 days from the day of discharge and no intervening admissions. . (Day of discharge counts as day 0) Also counts if C.difficile is identified on readmission to your facility.
If the time of admission and/ or the time of diarrhea onset and/or the time stool was collected are not available, CDI can be considered to be healthcare facility onset if onset of diarrhea, with a positive stool occurs on or after the third calendar day after the day of admission (which is day zero).
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EACH PATIENT ONLY COUNTS ONCE
Within 8 weeks of index diagnosis
C. difficile (CDI) Collaborative Definition
A patient readmitted after 8 weeks counts as a new patient /case
(E.g. Monday admit, day 4 = Thursday)
FACILITY HA-CDI RATE
# HA CDI cases / 10,000 Patient Days
(exclude NICU days)
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Example of a Run Chart
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Presentation Objectives
Demonstrate how one hospital used the new CDI surveillance definitions to identify an increase of CDI on one nursing unit.
Describe enhanced environmental controls to reduce transmission of CDI
Describe the new Clostridium difficile Infection (CDI) Collaborative Definition
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THE END
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