CDiff: Evidence Based Strategies for Source · PDF fileBased Strategies for Source Control Kathleen M. Vollman MSN, RN, CCNS, ... Accessed at ‐hiin.org. ... •> 3 days HO,

C‐Diff: Evidence Based Strategies for

Source ControlKathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN

Clinical Nurse Specialist / Educator / ConsultantADVANCING [email protected]

Northville Michiganwww.Vollman.com

©ADVANCING NURSING LLC 2017

Disclosures for Kathleen Vollman

• Consultant‐Michigan Hospital Association Keystone Center

• Consultant/Faculty for CUSP for MVP—AHRQ funded national study

• Subject matter expert for CAUTI and CLABSI for CMS/HEN 1.0 & 2.0

• Consultant and speaker bureau for Sage Products LLC

• Consultant and speaker bureau for Hill‐Rom Inc

• Consultant and speaker bureau for Eloquest Healthcare

Objectives for the Day

• Identify risk factors for the development of C‐Diff• Discuss strategies within and beyond the bundle to sustain reduction or elimination C‐Diff

• Shape strategies for implementation and address challenges

• Outline a test of change for your organizaiton

Notes on Hospitals: 1859

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Florence Nightingale

Advocacy = Safety

Protect The Patient From Bad Things Happening on Your Watch

Interventional Patient Hygiene

• Hygiene…the science and practice of the establishment and maintenance of health

• Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies

Central line catheter insertion and maintenance program

INTERVENTIONAL PATIENT

HYGIENE(IPH) Oral Care/ Mobility

VAP/HAP

Catheter Care

CA‐UTI CA‐BSI

Skin Care/ Bathing/Mobility

HASISSI

Patient

Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

Falls

PATIENT

CLEAN GLOVES

CLEAN GLOVES

HAND HYGIENE

HAND HYGIENE

Attitude &

Accountability

Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care

NSO

Achieving the Use of the Evidence

ValueVollman KM. Intensive Crit Care Nurs, 2013;22(4): 152‐154

Building Resiliency Into Interventions

S t rongest

STRENGTH OFINTERVENTION

Weakest

9

Forcing functions and constraints

Automation and computerization

Standardization and protocols

Checklists and independent check systems

Rules and policies

Education and information

Vague warnings – Be more careful!

Why HAI's?Protecting Patients From Harm

Estimates: 183 Hospitals in 10 StatesHAI: 722,000/year

HAI-related deaths: 75,000/yearHospitalized patients

develop infection: 1 out of 25 (4%)Death due to

sepsis/septic shock: 700/day

Money spent: $45 billion/yearIncrease risk of

readmission:27days vs. 59 days

Magill SS, et al. New England Journal of Med, 2014;370:1198-208

Hospital Performance Based Payments

8% of Based DRG

Payments at Risk by 2017

Hospital Acquired Conditions 1% reduction to total

DRG payments

Readmissions 3% reduction

Value Based Purchasing (VBP) 2% reduction

EMR Meaningful Use Requirements Reductions up to ¾ of

update factor

CAUTI & CLA‐BSICLA‐BSI,CAUTI & C‐diff

CLA‐BSI,CAUTI & C‐diff

2018 expanded to wards

Economic Burden of HAI’s: Build The Business Case

• Generated point estimates for attributable cost & LOS• 5 Major Infections=9.8 billion

• SSI’s, CLABSI’s, VAP/VAE, CAUTI’s, C‐Diff• SSI’s (33.7%)• VAP (31.6%)• CLA‐BSI (18.9%)• C‐Diff (15.4%)• CA‐UTI <1%

SSI CLABSI VAP CAUTI C‐Diff

$20,785 $45,814 $40,144 $896 $11,285

Per Case Basis

Zimlichman E, et al. JAMA Intern Med, 2013; 173:2039-46

50% HAI’s

Preventable

Strategies to Decrease C‐diff

What is C‐diff?

C‐diff• Clostridium difficile (C. difficile) is an anaerobic, spore‐forming bacteria spread through fecal‐oral transmission

• C. difficile infection (CDI) colonizes the large intestine and releases two toxins

• Causes a number of illnesses; diarrhea, colitis and sepsis.• Transmission: contaminated environments and health care personnel hands

• Antimicrobial therapy most important risk factor for CDI infection• longer courses• multiple antibiotics• Fluoroquinolones ↑the risk.

• Other drug may disrupt colonic flora; gastric acid suppression*, chemotherapy

Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret‐hiin.org.Howell MD, et al. Arch Intern Med. 2010;170(9):784‐790

HAI’s in the US: Point PrevalenceEstimates: 183 Hospitals in 10 States

HAI: 722,000/yearHAI-related deaths: 75,000/year

Hospitalized patients develop infection: 1 out of 25 (4%)

Death due to sepsis/septic shock: 700/day

Money spent: $45 billion/yearIncrease risk of

readmission:27days vs. 59 days

Magill SS, et al. New England Journal of Med, 2014;370:1198-208

Magill SS et al. NEJM 2014;370:1198‐208

CDI contributed to half of a million infections and directly led to approximately 15,000 deaths in one year

NHSN Definitions

• Healthcare Facility Onset (HO): • > 3 days after admission

• Community Onset (CO): • Inpatient < 3 days after admission

• Community‐Onset Healthcare Facility‐Associated: • Patient discharged from HCF < 4 weeks prior

Standardized Infection Ratio (Goal < 1)SIR = # HO CDI Observed

# HO CDI Expected

Burden of Clostridium difficile Infection in the United States

• Magnitude of CDI in the US continues to evolve• Estimated # of CDI infections was 453,000 in 2011

• Persons > 65 years (RR 8.65; 95% CI (8.16, 9.31)

• Estimated 29,300 deaths in 2011• 2.4 to 8.9 deaths per 100,000

• ¼ come from hospitals, remainder nursing homes and community settings

Lessa FC, et al. N Engl J Med 2015;372:825‐34.

• Attributable cost/patient: $6,100‐11,300• Associated with longer length of stay (~3 days increase) and readmissions (22% under 30 days)

• CDI reoccurs in 15‐35% of pts with 1 previous event, 33‐65% in pts with > 2 episodes of CDI

• Publicly reported • Costs related to CDI are estimated at $4.8 billion for acute care facilities alone

• Rates linked to the Hospital‐Acquired Condition (HAC) and Value Based Purchasing (VBP) programs

Clostridium difficile Infection is Costly

Dubberke ER, et al. Clin Infect Dis 2012;55:S88–92; Zimlichman E, et al. JAMA Intern Med 2013;173(22):2039‐46Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret‐hiin.org. Butler M,et al. Early Diagnosis, Prevention, and Treatment of Clostridium difficile: Update. Comparative Effectiveness Review No. 172. AHRQ Publication No. 16‐EHC012‐EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2016.Deshpande A, et al. Am J of Infect Control. 2017 in press

C‐Diff Infections in Surgical Patients

• Single center study, 600 bed tertiary, academic medical center• Retrospective review over 4 month period, patient had surgery (othro, neuro, trauma and general)

• + for HA‐C‐diff (3 days post admission, 12weeks post discharge

• Multivariable analysis of surgical patient risk factors• Results: 52 cases

• 0.80 cases per/1000 pt days• Risk factors: ASA classification of 4‐5/ 15 fold ↑, pervious 6 month an bio c use a 2.2 fold ↑, Periopera ve an bio c beyond 24hrs a 3.34 fold ↑, number of admission in the past yr.

Bernatz JT, et al. Infect Control Hosp Epidemiol 2017;38:1254‐1257

HHS SIR Goal: 0.7

HIIN Network Goal: 20% Reduction

CDI Prevention Efforts Should Focus on Community‐ and Facility‐based Antimicrobial Stewardship and

Preventing Disease & Transmission.

Gap Analysis

Tier 1: First Steps to Address C. diff.• C. diff surveillance

• Appropriate & timely testing of suspect cases• > 3 days HO, < 3 day CO• Appropriate testing

• Clinically significant diarrhea without other obvious causes.• Use recommended stepwise testing method

• Antibiotic Stewardship• Eliminate unnecessary antibiotic use• Use antibiotics with lower risk for promoting CDI

• Contact Precautions; order at time of ordering C. diff. test• Hand Hygiene• Glove and Gown use • Patient specific equipment and disinfection prior to use with others

• Effective and thorough cleaning and disinfection processes

• Effective Hand Hygiene Program• Environmental Cleaning

Stewardship and CDI Testing

• Only test symptomatic patients• > 3 unformed stools per day within 1 to 2 days• Lab should refuse formed stools test• Asymptomatic colonization rates high (10%)

• Don’t test if received laxatives within past 24 hrs• Don’t retest within 7 days/Lab hard stop• Discontinue test if not collected within 24 hrs• Time of test = placement into contact precautions

• Timely recognition of symptoms

Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret‐hiin.org. Dubberke ER, et al. Infection Control and Hospital Epidemiology, 2014;35(6):628‐645

Strategies for CDI Testing

Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret‐hiin.org.

CDI Testing• Rapid diagnosis will lead to prompt treatment & implementation of contact precautions that can limit the spread of CDI in the environment of care

• Polymerase chain reaction (PCR) tests have a sensitivity of 90 percent or greater and a specificity of 95 percent or greater

• Some facilities use a two‐step approach as a method of detection: 1) the stool is first tested for GDH and toxins and 2) indeterminate results then undergo PCR analysis.

CDI is a clinical Diagnosis; no test makes the diagnosis of CDI


Antibiotic Stewardship• Program that promotes appropriate selection, dose, route and duration of antimicrobial therapy

• Primary goal: optimize clinical outcomes while reducing unintended consequences of antimicrobial use

• Toxicity• colonization of pathogenic organisms• Antibiotic resistance

• Secondary goal: reduce health care costs associated with diseases such as CDI and antimicrobial resistance.

• Comprehensive programs both large & small hospitals shown ↓ in an microbial use between 22%‐36% with annual savings of $200,000 to $900,000.


Antibiotic Use: What’s The Issue• 30% to 50% of all antibiotic use is inappropriate• Inappropriate use includes:

• Longer than necessary duration of therapy• Treatment of nonbacterial diseases• Treatment of contaminants or colonizers

• Meaningless duplicate therapy (e.g., treatment with multiple antibiotics targeting anaerobes simultaneously)


Monitoring and analyzing antimicrobial use by disease, unit and practitioner can increase organizational knowledge of opportunities for stewardship

Antibiotic Use Among 323 U.S. Hospitals

MMWR March 7, 2014 / 63(09);194‐200

Greatest Risk

Model estimates that 30% reduction in use of broad-spectrum antibiotics will result in a 26% reduction in CDI.

• Receipt of antibiotics in prior patients was significantly associated with incident CDI in subsequent patients (log‐rank P < .01)

• This relationship remained unchanged after adjusting for other factors known to influence risk for CDI (receipt of antibiotics by the subsequent patient, prior patients developed CDI).

England’s Experience – Key Points

• Significant reduction in hospital quinolone use was associated with a near eradication of quinolone‐R C. difficile (67% resistance to 3%)

• Quinolone‐R strains did not re‐emerge after an increase in quinolone use

• Cephalosporin restriction and enhanced infection control was not responsible for the demonstrated reduction in CDI given lack of decrease in quinolone‐S C. difficile

Key Prevention Action Steps• Monitor Healthcare Effectiveness Data and Information Set (HEDIS) performance measures on antibiotic utilization in pharyngitis, upper respiratory infections and acute bronchitis.

• Eliminate redundant combination antimicrobial therapy • Adopt guidelines for managing CAP using a shorter course • Educate prescribing clinicians about appropriate selection, use dose, timing and duration of treatment

• Focus efforts on reducing the use of certain antibiotic classes associated with CDI, such as cephalosporins, clindamycin and fluoroquinolones

• Limiting the formulary and requiring pre‐authorization for certain antibiotics is a key strategy in reducing unnecessary use of antibiotics


(1) Remove unnecessary antibiotics from the formulary, (2) restrict options for duplicate antibiotics and antibiotics for special circumstances, (3) provide ongoing surveillance of antibiotic use by pharmacy, and (4) escalate to physician leaders as necessary—all of which leads to improved accuracy of antibiotic use.

©2017 Trinity Health 37

Proper Hand Hygiene and disinfection of surfaces can help

prevent the spread of C diff.

Hand Hygiene is the Single Most Important Factor in Preventing

the Spread of Infection

Jullian‐Desayes I, et al American Journal of Infection Control 45 (2017) 51‐8

Guidelines for Hand Hygiene in Health Care Settings• If hands are not visibly soiled, use an alcohol‐based hand rub 62% for routinely decontaminating hands in all other clinical situations (20‐30 seconds) (II)

• When hands visibly soiled or exposure to potential spore forming organisms, wash with either a non‐antimicrobial or antimicrobial soap & water (40‐60 seconds) (II). Can still use ABH in non‐outbreak C‐diff settings

• Do not use Triclosan containing soaps• Use gloves with CDI• Decontaminate hands after removing gloves• Provide HCW with hand lotions & creams to minimize occurrence of irritant contact dermatitis

• Use multidimensional strategies to improve hand hygiene practice (IA)

• Do not wear artificial fingernails or extenders CDC. Hand Hygiene Guidelines: MMWR 2002; 51(No. RR-16):[1-45]WHO Hand Hygiene Guidelines 2009Ellingson K, et al. Infect control & Hosp Epidemiology, 2014;35(2): S155-S178

When to Wash

Pittet D. Infect Control Hosp Epidemiol, 2009;30(7):611-622WHO Hand Hygiene Guidelines 2009Ellingson K, et al. Infect control & Hosp Epidemiology, 2014;35(2): S155-S178

Wash In

Wash Out

Similar rates of HH complianceSunkesula VCK, et al AJIC, 2015;43:16019

Key Components to Multimodal Strategy to Improve Adherence (II)

• Education & motivation & strong commitment to improve hand hygiene by frontline workers & leadership (Institutional safety climate

• Engage staff in the process• Simply & standardize• Alcohol‐based hand rub as primary method for hand hygiene….right product

• C‐diff‐wear gloves & gown/both methods of hand hygiene are not real effective

• Reminders in the workplace/red line approach• Verified by competency, monitored compliance and feedback/weekly initially (II)

WHO Guidelines 2009Pittet D. Infect Control & Hosp Epidemio, 2008;29:957-959Sax, H., et. al. Infection Control and Hospital Epidemiology 2009, 28, 1267-1274Erasmus, V. et. Infection Control and Hospital Epidemiology.2009 30(5), 415-419Bonuel N, et al. Critical Care Nursing Quarterly, 2009;32:144-148Ellingson K, et al. Infect Control & Hosp Epidemiol, 2014;35(S2):S155-178

Catchy & Emotional Signs

Hand Hygiene Measurement Methods• Direct Observation

• Srigley et al demonstrated, in 2014, that HCWs were 3x more likely to clean hands when in the line of sight of a direct observer! A 300% Hawthorne Effect

• Product Usage/Volume• Automation monitoring can improve compliance

• Electronic versus direct observation more accurate in measuring compliance

• Morgan DJ, et al. AJIC, 2012;40:955‐959

Haas and Larson Journal of Hospital Infection 2007;66:6-14Polgreen PM, et al. Infect Control & Hosp Epidemiol, 2010;31:1294-1297Ellingson K, et al. Infect Control & Hosp Epidemiol, 2014;35(S2):S155-178

3 Types of Electronic Monitoring

• Group Monitoring –Non Badge Based

• Individual or Group Monitoring –Badge Based (Stand Alone)

• Individual or Group Monitoring –Badge Based Enabled with a Real Time Locating System (RTLS) Infrastructure

Capable of Capturing 100% of HHEs and Eliminating the Hawthorne Effect along with the Practice of Secret Shoppers Seeing Non Compliance and Allowing Care to Proceed Anyway

Contact Precautions• Order at time of ordering C. diff. test

• Hand Hygiene• Glove and Gown use • Patient specific equipment and disinfection prior to use with others

• Use disposable equipment or dedicate equipment to a single patient (e.g., blood pressure cuffs, thermometers, commodes).

• Use commode liners to limit splashing or contamination when emptying

• Effective and thorough cleaning and disinfection processes

• Define who is responsible for cleaning ventilators, IV pumps and other critical patient care equipment.


The Environment: What is the Problem?

All these studies found a patient is at increased risk of picking up pathogens like, MRSA, VRE, & C. diff. when admitted to room where prior patient had one of these

• Huang SS (2006)1

• Drees M (2008)2

• Zhou Q (2008)3

• Moore C (2008)4

• Hamel M (2010)5

• Shaughnessy et al. 2011

1. Huang SS, et al. Arch Intern Med. 2006;166(18):1945‐1951.2. Drees M, et al. Clin Infect Dis. 2008;46(5):678‐685.3. Zhou Q, et al. Infect Control Hosp Epidemiol. 2008;29(5):398‐403.

4. Moore C, et al. Infect Control Hosp Epidemiol. 2008;29(7):600‐606.5. Hamel M, et al. Am J Infect Control.

2010;38(3):173‐181.

C‐Diff‐Environmental Impact

• CDI spores can survive on surfaces for as long as five months.

• CDI spores were found in 49% of the hospital rooms occupied by patients diagnosed with CDI,

• 29 % of the rooms of asymptomatic CDI carriers • The most heavily contaminated areas were hospital room floors, bed rails and bathrooms


50©2017 Trinity Health

Examples of High Frequency Touch Surfaces; Patient Room

Use specialized privacy curtains that can be replaced without a ladder and appropriately cleaned & Attach disposable, plastic adhesive shields to privacy curtains to prevent glove or hand contact and contamination

Reducing the Load in the Environment: Cleaning of Patients Room

• Develop procedures for routine disinfection of environmental surfaces with an EPA‐registered sporicidal disinfectant1

• Use a 1:10 dilution of 5.25% sodium hypochlorite• Use bucket method for appropriate kill time2

• Use audible timers to ensure appropriate contact time for cleaning agents

• Use bleach wipes as an adjunct 2

• Use a two‐step cleaning protocol incorporating mobile, automated equipment that releases ultraviolet‐C radiation or hydrogen peroxide vapor3,4

1. Siegel JD, et al. Available at: http://www.cdc gov/hicpac/pdf/isolation/isolation2007.pdf. Accessed April 4th, 2013.2. APIC’s Guide to Preventing Clostridium difficile Infections (2013). Available at

http://cdiff2013.site.apic.org/about‐the‐conference/new‐c‐diff‐guide. Accessed on April 4th, 2013. 3. Nerandzic MM, et al. BMC Infect Dis 2010 Jul 8;10:1974. Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago,

IL: Health Research & Educational Trust. Accessed at www.hret‐hiin.org.

Effect of Ultraviolet Light on C‐Diff Spore Recovery vs. Bleach Alone• Evaluate effectiveness of manual cleaning and UV‐C on inpatient hospital room surfaces

• Measured CFUs on 9 high touch surfaces after bleach cleaning & after UV‐C cleaning

• 3 tower system. Bathroom done daily & inpatient room on discharge

Liscynesky C, et al. Infect Control & Hospital Epidol. 2017;38(9):1116-1117

Bleach alone: 13% positive for C‐diff > 10 CFU’sBleach & UV‐C: .4% positive for C‐diff > 10 CFU’s

Toilet seat and over bed table most commonly + sites

Oxycide [ECOLAB]

©2017 Trinity Health 53

• Works on all surfaces

• One‐step cleaner, disinfectant and sporicidal

• Less chemicals=less cost

• Contact time is 3 min for C. difficile spores

5 min for HBV & HCV

• Two Active ingredients:▪ PERACETIC ACID breaks down outer membrane of the spore, bacteria or virus

▪ HYDROGEN PEROXIDE destroys the inner component (DNA, proteins)

Helps reduce risk and cost of replacing damaged goods. Does not corrode surfaces, damage mattresses or soft goods

Consider Stool Containment

•Potential to Reduce Skin Injury• IAD is a type of irritant contact dermatitis (inflammation of the skin)

• IAD 5x more likely to develop a HAPU

•Reduce Exposure to Harmful Microorganisms

Giuliana K. Presented at the CAACN September 25‐27th Winnipeg, Manitoba, CAGray M. Presenting a Wound Care Conference, 2016, New York City, NY

2 Step Process for Fecal Containment• If the perianal skin is not intact• Stool culture positive

• If the rectum is intact• Patient is neutropenic• Stool culture negative

Evidence Based Review & Recommendations

• Jan 2009 to April 2015• 3236 articles screened• 261 meet criteria for review• 46 studies included• Quality‐82% (QI‐MQCS)• Results:

• Twice daily disinfection of high touch surfaces & terminal cleaning with chlorine based products ↓ CDI 45% to 85%

• Bundled interventions & antibiotic stewardship showed promise for ↓ CDI Louh IK, et al. Infect Control Hosp Epidemiol

2017;38:476–482

Tier 2: Enhanced Practices; Escalation of Tactics in Tier 1 Implemented but No Decrease Seen

• Define the opportunities for improvement• Focused review of hospital onset C. diff. cases

• Consider prompt assessment & expedite specimen submission for testing; “time to isolation?”

• Same rooms versus different rooms?• Review Antibiotic use• Review Testing practices• Check Timing of Contact precaution & compliance • Shared equipment? • Review type and practices around sporicidal surface disinfectant

• Consider supplemental disinfection strategies

58Intervene based on opportunities found

HRET, C‐Diff Change Package, 2017

Driving Change

Structure

Process

Outcomes

• Gap analysis• Build the Will• Protocol

Development

• Make it Prescriptive

• Overcoming barriers

• Daily Integration

Thank You

Targeted Assessment for Prevention (TAP) Strategy

Target → Assess → Prevent

• Target facilities/units using TAP Report function available in NHSN

• Assess gaps in infection prevention in targeted facilities/units using Facility Assessment Tools

• Prevent infections by implementing interventions to address the gaps using Implementation Guidance

http://www.cdc.gov/hai/prevent/tap.html

http://www.cdc.gov/hai/prevent/tap.html

Using a Measure to Help Target Prevention Efforts to Reach HAI Reduction Goals:Cumulative Attributable Difference (CAD)

CAD OBSERVED PREDICTED ∗ SIRtarget

• Target SIR can be chosen based on goals of a group, state, organization, or national target

• Lower target SIR → larger CAD (“excess” number of infections)

• NHSN uses HHS target SIRs• CAD is the number of infections needed to prevent to reach the target SIR

Courtesy of Minn Soe, CDC

Cumulative Attributable Difference (CAD)

0

1

2

3

4

5

6

7

8

Observed Predicted

NumberOf

Infections

CAD = observed – (predicted *0.55) = 4.967.0

3.7

What Data/Information Do You Need So That You Can Decrease the Number of Infections at Your Facility?

• Infection rates and Device utilization ratios• SIR for CAUTI, CLABSI and CDI

• Identified targets—what SIR should you be striving for? (national, state or organization/health system specific

• Can use the CAD to help you understand how many infections you need to prevent

What Data/Information Do You Need So That You Can Decrease the Number of Infections at Your Facility?• Gap analysis related to prevention practices

• What are the research supported prevention practices and which of these have you implemented?

• Process data• How reliably are you performing each of the prevention practices?

• Learning from Defect• When you have an infection—taking a deep dive into finding out why it occurred?

Your Turn, Try a Test of ChangePlanning Worksheet

When will you compare what happened to your prediction?

When will you decide what to do next?

SMALL TEST OF CHANGE

WHATdo you need to test this idea?

WHOwill be involved in the tests?

HOWwill you inform participants?

WHEREwill the test occur?

WHENwill the test occur?

HOWwill you know it is successful?

SMALL TEST OF CHANGE

What did you predict will happen?

What happened? What did you learn? What are the next steps?

Table Exercise: Develop a Small Test of Change

• Look at your data:

• Gap Analysis: what evidence based interventions are you not doing?

• Process data: how well are you implementing all of the science

• Review evidence based practices and processes previously shared

Identify one small test of change you would like to implement to improve your 3hr bundle sepsis compliance

Complete Test of Change worksheet Share with group

CDiff: Evidence Based Strategies for Source · PDF fileBased Strategies for Source Control Kathleen M. Vollman MSN, RN, CCNS, ... Accessed at ‐hiin.org. ... •> 3 days HO,

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