Clostridium Difficile Patients In the Endoscopy Center The Implications, Criteria and Processes for Performing Positive or Suspected Positive C-Diff. (CDI) Patients in the GI Center Kim Reints, RN, BSN, PHN, CNOR

What is C-Diff? A bacteria found in feces Spore forming Gram positive Anaerobic Excretes 2 toxins Mainly spread by persons (healthcare workers) that touch surfaces contaminated with feces through hand contact Can live for long periods on surfaces and clothing of patients and health care workers

The Scope of a C-Diff. GI Infection The CDI Infection The Scope of a C-Diff. GI Infection Asymptomatic Colonization Community Acquired (CA) Severe Diarrhea Pseudomembranous Colitis Toxic Megacolon Colonic Perforation Death

Risk Factors for C-Diff Infection Hospitalization or a prolonged length of stay in a healthcare setting such as a long term care facility (nursing home). Antibiotic overuse or misuse; including clindamycin, cephalosporin's and fluoroquinolones. Aged > or = 65. The usage of acid suppression therapy, particularly the use of Proton Pump Inhibitors (PPIs). The usage of Histamine 2 receptor antagonists Increasing comorbidities such as dementia, peripheral vascular disease, etc. Community acquired (CA) found to have younger age & no recent antibiotic exposure

Illustration of Clostridium Difficile Spore

Watery diarrhea with at least 3 bowel movements per day for 2-3 days Symptoms of C-Diff. Watery diarrhea with at least 3 bowel movements per day for 2-3 days Fever Loss of appetite Nausea Abdominal pain and tenderness

URGENT, SERIOUS & CONCERNINIG IC THREATS In 2013 the CDC published a report outlining the top 18 drug-resistant threats to the United States. These threats were categorized based on level of concern: urgent, serious, and concerning. Threats assigned to the urgent and serious categories require more monitoring and prevention activities, and threats in the concerning category require less and take into account the epidemiology of the infectious agent and to address any gaps in the ability to detect resistance and to protect against infections. CDI is at the top of the Urgent list

What Does the ASC or Endoscopy Center Do? Standard & Contact Precautions – CDI is a virulent bug There is a large increase in CA C-Difficile CDC says isolate these patients immediately – even suspected All persons who care for these patients or their items must wear gloves and gowns. After removal of gloves, hands must be washed with soap and water, And then hand sanitizer (new IC hand hygiene recommendations). All room surfaces and items used for the patient must be cleaned with and EPA registered spore-killing disinfectant (with bleach). The floor of the procedure room should be mopped where the stretcher was – coming from CMS surveys.

Does Your Staff have Hand Hygiene Intelligence? All Staff caring for the C-Diff patient must don gloves as gloves decrease the risk of C-Diff transmission by the health care worker. This means even in Pre-op and Pacu. Alcohol does not kill C-Diff spores, therefore alcohol based hand sanitizer is ineffective. Gloves must be removed properly to prevent hand contamination. Soap and water is superior to removing C-Diff spores and antibacterial soap is highly suggested. New hand hygiene guidelines suggest using an alcohol based hand sanitizer after soap and water.

Cleaning, Disinfecting and the Killing of C-Diff. Spores Does your Center have an EPA Registered Disinfectant with Bleach? Have you read the label for contact times? Have you read the label on how to use the wipes? (Some recommendations say you must use 2 wipes) Does your staff know the contact times for the wipes you have and they are using? (You cannot make a wet bed). Have you educated your staff on contact times, bed making and contact time for killing of C-Diff spores? (Dispatch wipes state 5 minutes).

EPA Registered Disinfectants with Bleach 9402-13 Kimtech Germicidal Wipe 9480-8 PDI Sani-Cloth Bleach Wipes 56392-8 Dispatch Hospital Cleaner Disinfectant Towels with Bleach 70590-1 Hype Wide Disinfecting Towel with Bleach

How Effective is Endoscopy for Diagnosing C. Difficile? According to Medscape, November, 2016: “Endoscopy is less sensitive for diagnosing C-Diff. than stool assays.” “Endoscopy may show the presence of raised, yellowish white, 2 to 10 mm plaques overlaying and erythematous edematous mucosa. These plaques are termed pseudo membranes. “Endoscopic findings may be normal in patients with mild disease or may demonstrate nonspecific colitis in moderate cases.”

What is Your Policy for treating patients with C-Diff? To ensure proper cleaning of the center of a known or suspected case of C. Difficile. PURPOSE: To prevent the spread of C. Difficile to staff and patients. PROCEDURE: All rooms and equipment (monitors, stretchers, bed rails, blood pressure cuffs, stethoscopes, monitoring cords, etc.) used on patients with known or suspected cases of C. Difficile will be cleaned and wiped down with bleach wipes and allowed to air dry thoroughly. All manufacturer instructions of EPA Registered disinfectants that kill spore bacteria will follow manufacturer’s instructions prior to use for another patient. Staff will use standard hand washing precautions using soap and water, followed by the use of alcohol based hand sanitizer, after patient contact and room/equipment cleaning.  These patients should be scheduled as the last patients of the day.

Who Are Your at Risk Patients? Nursing home or long term care patients Patients that have been hospitalized numerous times in the last 3-6 months (Diagnostic Summary?) Patients on PPI Patients on H2 Inhibitors Patients that state they have had ongoing bouts of diarrhea with or without treatment Patients on long-term antibiotic therapy Some patients may say I have or have had C-Diff and they do not know the resolution of the CDI Patients that show up at office visits with un-diagnosed diarrhea should have an assay test pre-procedure

Educate your Physicians and Staff These patients should be scheduled as the last patients of the day in the center. You physicians and staff need to know the communicable nature of C-Diff. The center will need to purchase extra gowns and gloves The same nurse should provide care to the patient The center will need to purchase bleach cleaning wipes and floor cleaner Mopping between patients The staff will have to have extra scrubs on site for care of the C-Diff. patient All bathrooms will need to be cleaned after use by the C-Diff patient Room turnovers will take longer Each room will need to be terminally cleaned between each patient with bleach wipes as will equipment Does your center have the ability to sequester these patients from other patients?

Take Policy to the Board Whatever your policy is you must take it to the Board to get consensus and adoption The Board must understand the epidemiology of CDI and caring for these patients. There will be extra time, supplies and resources in caring for which equates to extra costs for the Center Look at your policy for home-laundered scrubs worn into the center

Screen Patients for C-Diff be Ready It all starts at the physicians office for patients with diarrhea with unknown origin. They should have assay testing. Are patients being asked about new or old problems with diarrhea? Are patients being asked about antibiotic therapy for diarrhea? Are patients coming from long term care facilities? Is anyone calling the long term care facility or nursing home about the patient and their past and present conditions such as C-Diff? Are your staff educated about Contact and Universal precautions for existing or suspected patients with C-Diff? Have your staff been educated about the use of PPE and the use of bleach solutions to kill C-Diff? How is your housekeeping company notified about C-Diff and the use of bleach products? Has the patient been on vancomycin for diarrhea?

Be Ready – Get Prepared There must be policy There must be process Your staff must be educated Your staff must know proper use of PPE Your staff must know how to don and remove gloves appropriately Your staff must know how to terminally clean a room and all patient care equipment and supplies Protect patients, your staff and your Center

Resources & Websites Centers for Disease Control and Prevention. Retrieved from: http://www.cdc.gov/hai/organisms/cdiff/cdiff_clinicians.html http://www.cdc.gov.hai/organisms/cdiff/cdiff_settings.html EPA’s Registered Antimicrobial Products Effective against C-Diff Spores. List K. Retrieved from: https://www.epa.gov/sites/production/files/2016- 06/documents/list_k_clostridium.pdf Infection Control Today. Expert reviews strategies for C. diff transmissions prevention. Retrieved from: http://www.infectioncontoltoday.com/PrinterFriendly.aspx/?id Medscape. Clostridium Difficile Colitis Treatment & Management. Retrieved from: http://emedicine.Medscape.com/article/186458-overview http://emedicine.Medscape.con/article/186458-overview

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