Multidisciplinary Partnerships to Reduce Clostridium difficile Infection: A Success Story Laura Johnson, MD Hospital Epidemiologist, Infectious Diseases.

Multidisciplinary Partnerships to Reduce Clostridium difficile Infection: A Success Story

Laura Johnson, MDHospital Epidemiologist, Infectious DiseasesHenry Ford Health System

Rachel Chambers, PharmDPharmacy Specialist, Antimicrobial StewardshipHenry Ford Hospital

Objectives

The burden and severity of Clostridium difficile infection (CDI) has dramatically increased in recent years

Multidisciplinary collaboration is key to minimizing CDI in the health care setting

This presentation will provide an overview of the key players and multidisciplinary interventions necessary to successfully manage and reduce CDI

Clostridium difficile Infection (CDI)

Bacterial infection of colon resulting in spectrum of disease from mild diarrhea to severe colitis with sepsis, toxic megacolon, and even death.

Spores persist in healthcare environment and are transmitted by fecal-oral route. Hands and Environment

Antibiotic exposure kills off normal protective gut flora and C. difficile can grow and produce toxins, resulting in disease.

Yearly Clostridium difficile–related Mortality by Listing on Death Certificates, United States, 1999–2004.

Redelings MD, et al. Emerg Infect Dis. 2007;13:1417-1419

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Increased and Severe CDI at HFH

2007/8: Patients noted to have severe CDI, some requiring colectomy 1988 to 2007: 8 colectomies March to May 2008: 7 colectomies

Surveillance of CDI Initiated

HFH Nosocomial C. diff Rates 2008-2009

0.0

10.0

20.0

30.0

40.0

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Rate 22.6 14.8 21.5 31.3 24.7 19.3 14.7 17.3 16.8 17.2 26.3 24.0 23.3 21.7

Benchmark 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00

JAN FEB MA APR MA JUN JUL AU SEP OCT NO DEC JAN Feb

Investigation of Problem

Infection Prevention started surveillance program

Deep dive into severe CDI cases Collaboration of Infection Prevention, Pharmacy, Clinical

Quality and Safety Office, and Care Providers

Guidelines for C. difficile Prevention and Control

CDC Prevention Strategies: Core

Contact Precautions for duration of diarrhea Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and environment Laboratory-based alert system for immediate notification of

positive test results Educate about CDI: HCP, housekeeping, administration,

patients, families

http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.htmlDubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.

CDC Prevention Strategies: Supplemental

Extend use of Contact Precautions beyond duration of diarrhea Presumptive isolation for symptomatic patients pending

confirmation of CDI Evaluate and optimize testing for CDI Implement soap and water for hand hygiene before exiting room of

a patient with CDI Implement universal glove use on units with high CDI rates Use sodium hypochlorite (bleach) – containing agents for

environmental cleaning Implement an antimicrobial stewardship program

http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html

Implementing CDC Guidelines Requires a “SWOT” Team

Clear guidelines to prevent and control C. difficile

The challenge

Implementation Sustainability

C. difficile Task Force created To identify and address our “strengths, weakness, opportunities and

threats” To reach multiple disciplines in hospital and facilitate buy-in To change practice and culture related to prevention and control

practices

C. difficile Task Force

Infection prevention practitioners Providers: infectious disease, medicine, surgery, intensive care,

gastroenterology Nursing (general practice, intensive care, front line and educators) Pharmacy Laboratory Environmental services Facilities/plant operations Office of clinical quality and safety

Reporting to hospital leaders

Examples of Collaboration

Infection Prevention and Environmental Services Weekly rounds (with “bug meter”) Developed enhanced bleach cleaning protocols

Laboratory and Infection Prevention Improved turn around time for lab result Developed process for daily notification of results Enhanced lab testing with better sensitivity and specificity

Infection Prevention and ICU Nursing Team Developed protocol for RN-Initiated testing for CDI “Caboodles” for supplies to decrease contamination of supplies in room Eventually, protocol for “fecal transplant” for treatment of difficult cases

Transportation and Nursing Identified need to keep chart clean during transport – cover chart in plastic bag during

transportation

Examples of Collaboration

Inter-Nursing Collaboration Sticker on chart in addition to door sign for improved communication

Facilities, Nursing, Infection Prevention Identified areas with limited sinks and installed sinks on multiple floors Installed wall caddies for easy access to PPE Stickers on Alcohol Hand Rub canisters

Admissions Office, Nursing, Infection Prevention Extended Precautions till discharge Cohorting patients during room shortages

Surgeons and Infectious Disease Team Implemented trial of probiotic yogurt in ICU

Infectious Disease Fellows and Pharmacy Reviewed management of CDI cases daily with interventions as necessary

Enhancement of Antimicrobial Stewardship Program – A major collaboration with pharmacy colleagues…

The Case for Antimicrobial Stewardship

As much as 50% of antibiotic use is inappropriate

Inappropriate antibiotic use associated with poor patient outcomes, resistance development, increased health-care costs

Declining antibiotic pipeline in recent years

New Antibiotic Approvals

Modified from Spellberg B et al. Clin Infect Dis; 2008;46:155-64

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8

10

12

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1983-1987 1988-1992 1993-1997 1998-2003 2004-2007

Dellitt TH et al. Clin Infect Dis 2007;44:159-77.

Dellitt TH et al. Clin Infect Dis 2007;44:159-77.

Highlights of the Stewardship Guidelines

Multidisciplinary collaboration: stewardship team, infection control, Pharmacy &Therapeutics

Support from hospital leadership and medical staff Appropriate compensation (ideally through offices of quality/patient

safety) Administrative support to track outcomes 2 core strategies:

Prospective audit with intervention & feedback

Formulary restriction with preauthorization

Dellitt TH et al. Clin Infect Dis 2007;44:159-77.

Antimicrobial Stewardship Strategies

Component IDSA/ SHEA Guideline Strength of Evidence

Implemented at Henry Ford Hospital

Formulary restriction with audit and feedback

AI

Education AIII, BII

Guidelines, pathways AI, AIII

Antimicrobial cycling CII No

Antimicrobial order form BII

Combination therapy CII Not routine

De-escalation AII

Dose optimization AII

IV to PO Conversion AII

Dellitt TH et al. Clin Infect Dis 2007;44:159-77.

Henry Ford Hospital (HFH) Antimicrobial Stewardship Program (ASP)

What is it? A comprehensive system of health-care providers, pathways,

guidelines, order sets, and informatics designed to optimize antimicrobial utilization

Mission statement To improve patient outcomes through optimization of

antimicrobial therapy and support the education of health-care providers in appropriate antimicrobial use

7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004

Integration into Pre-Existing Structures

Strong Leadership

Dedicated Individuals Responsible for Antibiotic Use

Harnessing Existing Resources to Deliver Change

Obtaining Local Data on Prescribing and Resistance

Communication

Education and Training

Key Element Local Action at HFH

Quality and safety coordination of multidisciplinary CDI task force

Pharmacy and antimicrobial subcommittee ownership for antimicrobial stewardship

Recommendations implemented by antimicrobial subcommittee of Pharmacy & Therapeutics

7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004

Integration into Pre-Existing Structures

Strong Leadership

Dedicated Individuals Responsible for Antibiotic Use

Harnessing Existing Resources to Deliver Change

Obtaining Local Data on Prescribing and Resistance

Communication

Education and Training

Key Element Local Action at HFH

Quality and Safety coordination

Strong multidisciplinary involvement with Chief of Infectious Disease and Gastroenterology directly involved

Support from Director of Pharmacy Services, Chief Medical Officer, Hospital Administration

7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004

Integration into Pre-Existing Structures

Strong Leadership

Dedicated Individuals Responsible for Antibiotic Use

Harnessing Existing Resources to Deliver Change

Obtaining Local Data on Prescribing and Resistance

Communication

Education and Training

Key Element Local Action at HFH

Antimicrobial Subcommittee

Stewardship pharmacist

Stewardship rounds with Chief of Infectious Diseases

Infectious Diseases pharmacy residency program added

7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004

Integration into Pre-Existing Structures

Strong Leadership

Dedicated Individuals Responsible for Antibiotic Use

Harnessing Existing Resources to Deliver Change

Obtaining Local Data on Prescribing and Resistance

Communication

Education and Training

Key Element Local Action at HFH

Placing a higher priority on the “stewardship agenda” within existing clinical pharmacy and infectious diseases practice model

Pharmacy resident project dedicated to validation of CDI management algorithm

Infectious diseases fellows performed daily review of C. difficile infected patients

7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004

Integration into Pre-Existing Structures

Strong Leadership

Dedicated Individuals Responsible for Antibiotic Use

Harnessing Existing Resources to Deliver Change

Obtaining Local Data on Prescribing and Resistance

Communication

Education and Training

Key Element Local Action at HFH

Deep dive into C. difficile cases to identify “problem” antibiotics

Stewardship program efficiency improved with implementation of Theradoc® decision support software

Multidisciplinary task force members responsible for disseminating change to their department/ discipline

Presentations at grand rounds and departmental meetings

Policies and guidelines communicated in hard copy and on Intranet

National presentations and posters to describe the work (e.g. C. difficile management algorithm presented at ICAAC 2009)

7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004

Integration into Pre-Existing Structures

Strong Leadership

Dedicated Individuals Responsible for Antibiotic Use

Harnessing Existing Resources to Deliver Change

Obtaining Local Data on Prescribing and Resistance

Communication

Education and Training

Key Element Local Action at HFH

Antimicrobial Stewardship Website:Guidelines and Education

C. difficile Management Pathway

Adapted from: Drugs 2007; 67(4):487-502 and Infection Cont Hosp Epidemiol 2010; 31:431-455.

Treatment success was defined as clinical resolution of CDI by day 14 or end of treatment (EOT) and the absence of complications or relapse

Richardson C et al, abstract 423, IDSA 2009, Philadelphia, PA

Compliance with institutional pathway was associated with improved outcome

Priorities are set by antimicrobial subcommittee, identification of key messages for educational initiatives

Continuous improvement sought:

• Larger role for ID pharmacist and stewardship pharmacist

• More multidisciplinary education, ensure training is at an appropriate level for each group

• Increase involvement of ID fellows, hospital epidemiology, microbiology

7 Strategies for a Successful Stewardship ProgramCooke FJ, et al. Clinical Governance 2004

Integration into Pre-Existing Structures

Strong Leadership

Dedicated Individuals Responsible for Antibiotic Use

Harnessing Existing Resources to Deliver Change

Obtaining Local Data on Prescribing and Resistance

Communication

Education and Training

Key Element Local Action at HFH

Follow Through and Accountability

Guidelines are well established and often many eager participants – but challenge is to move process forward

Consistent data/messages to hospital leadership

Problem identified as a priority to leaders Capital and resources

Structure to support accountability Office of Clinical Quality and Safety Leaders and executive committees maintain accountability

Task Force Results

HFH Nosocomial C. diff Rates 2009-2011

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Rate 23.3 21.7 26.8 27.5 16.0 6.7 13.0 8.7 10.5 7.3 7.5 10.80 8.2 5.89 5.6 9.7 6.2 8.0 8.8 7.4 8.9 10.4 7.3 7.1 6.9 4.7 3.4 3.2 3.4 3.6 5.8 4.4 4.9

Benchmk 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00

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Summary

Implementing improvement projects with sustained results requires: Thorough investigation of problem/issue Communication to key leaders and front line staff Multidisciplinary team approach Process to hold key players accountable with support

from hospital leaders