LEAPT / GAPP Coaching Call C difficile Prevention Working Session July 3, :00 – 2:00 PM

Appreciative Moment LEADING EDGE ADVANCED PRACTICE TOPIC (LEAPT) CLOSTRIDIUM DIFFICILE AND ANTIMICROBIAL STEWARDSHIP 2

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3 Work Completed on C difficile by LEAPT Hospitals BOLD AIM: Reduce Hospital-Onset Clostridium Difficile (C. diff) in patients by 10% to 25% by December – Georgia: Goal: 10% Reduction 107,000 Patients Estimated National Rate Hospital-Onset C. diff in ,000 to 12,500 Nationally, the Potential Number of Lives Saved With a 10% to 25% Reduction of C. diff incidence 3

Learn. Act. Improve. Spread. Keep the Drum Beat Going PILOT SITES across the nation are leading this effort 6 Georgia Hospitals 4  St. Mary’s Healthcare: Lead  Crisp Regional  Effingham Health System  Newton Medical Center  South Georgia Medical Center  University Hospital

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 5 KEY LEARNINGS FROM LEAPT PILOT SITES: Positioned to spread best practices within our HENs and across the nation starting in May Provide mentor support and monthly coaching calls/webinars. Demonstrate the business case for patient quality and safety improvement in the area of C. diff. Continue to expand efforts to monitor bundle compliance in ‘real time’ – ensure implementing all bundle components. Develop/broadly implement EHR triggers and warnings. Collaborate and partner with others such as CDC, state Public Health HAI advisory committee, state health departments, QIOs, pharmacists and other partners to strengthen C. diff reduction efforts and antimicrobial stewardship programs in hospitals and the community. Engage other practice/provider settings, including physician offices, long term care, home health, pharmacies, and urgent care. Raise community awareness regarding appropriate antibiotic use and prevention of C. diff. 5

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6 C. DIFF OUTCOME MEASURES: INCIDENCE:  Hospital-Onset (HO) C. diff Incidence Rates – HO C. diff per 10,000 patient days  C. diff standardized infection ratio (SIR) for the adult patients ANBIMICROBIAL STEWARDSHIP:  Broad Spectrum Agent Use - Defined Daily Dose per 1,000 Patient Days for: Tigecycline Ceftaroline Daptomycin Linezolid ALL Cephalosporins 3rd Generation Cephalosporins 4th & 5th Generation Cephalosporins Carbapenems Extended Spectrum Penicillins Penicillins Quinolones 6

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 7 PROCESS MEASURES  Overall compliance with environment cleaning and individual cleaning components.  Overall compliance with isolation procedures for C. diff patients and individual bundle elements.  Adenosine Triphosphate (ATP) marker testing. 7

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 8 HOSPITAL TESTIMONIALS: The most beneficial aspect of LEAPT is the networking that we have been able to do to learn from each other. We learned through the small tests of change we did, that some assumptions we had made previously were not accurate, and this prompted us to change a process and re-educate the staff. — Georgia Hospital Association 8

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 9 WHY IT IS IMPORTANT TO WORK ON C. DIFF - THE HUMAN COST MP was a very loved volunteer at a MN Hospital. He was hospitalized for seven days after a cholecystectomy and small bowel resection. He returned three days after his discharge due to surgical complications. Eight days after his readmission MP tested positive for C diff. During this readmission, he stayed in the hospital for a total of 68 days largely due to health complications related to his C. diff infection. During this time, he had six surgical procedures (including a colectomy due to severe C. diff). He returned for seven additional readmissions that same year and had medical costs totaling more than $1.2 million. The following year MP spent 87 more days in the hospital and had medical costs that totaled more than $368,000. Stories like MP’s can be prevented with proper hand hygiene and holding others accountable for maintaining a safe environment for patient care. — Minnesota Hospital Association 9

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 10 RAPID CYCLE INNOVATIONS: 10

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Slide 11 11

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 12 Partnership to Reduce C. diff Identify mentor physicians and hospitals to serve as faculty and consult with hospitals beginning the journey. Collaborate and partner with other stakeholders to incorporate outside expertise and resources, such as CDC, state Public Health HAI advisory committee, state health departments, QIOs, pharmacists, and others to review bundle and make recommendations regarding strengthening antimicrobial stewardship programs and C. diff reduction in hospitals and community. 12

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 13 Implementation of Bundle Create a multi- track bundle that includes all aspects of C. diff reduction, including prevention, detection, treatment, and containment. Engage front line staff including nursing, pharmacy, environmental services, lab and others in rapid cycle testing and implementation of bundle elements. Incorporate the human factors approach to hand hygiene to remove barriers to hand hygiene and facilitate hand hygiene compliance in addition to engaging staff. 13

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 14 Antimicrobial Stewardship Collaborate with CDC to identify additional NHSN data analysis and Antimicrobial Stewardship measures. Establish a stewardship team led by pharmacists and physicians to support clinicians in making the best choice of antimicrobials for their patients. Develop guidelines on appropriate antimicrobial selection, dose and duration. Restrict broad spectrum antimicrobials based on defined use criteria. Evaluate antimicrobial use data and assess which classes require further attention. 14

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 15 Slide 15 15

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 16 Detection Recommendations for C. diff Testing. Reduce unnecessary culture practices (limiting the use of cultures to clinical evaluation). 16

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 17 Cleaning and Disinfecting Improve adherence with environmental cleaning: standardized protocol to environmental cleaning, standardized tool to check compliance with cleaning, and audits on cleaning. Pilot different ATP monitoring devices, including UV gel black lights, to assess high touch cleaning efficacy. 17

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 18 Slide 18 18

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 19 Isolation Improve compliance with isolation procedures (healthcare workers audits and feedback) and the availability of personal protective equipment and hand hygiene products. Use of a “Safe zone” for limited entry to room for contact isolation. 19

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 20 Community Approach Work with other providers, long term care facilities, Home Health, retail pharmacies and others to increase public knowledge regarding appropriate antibiotic use and reduction of C. diff. 20

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 21 RAPID EARLY REPORTING FOR IMPROVEMENT: 21 LEAPT HENS COMBINED C. DIFFICILE NHSN STANDARDIZED INFECTION RATIO (SIR)

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 22 PROCESS RESULTS: 22

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Georgia’s LEAPT C diff Prevention Leaders 23 GA LEAPT Hospital NAME/TITLECONTACT St. Mary’s Healthcare System - Lead Hospital Doug Effingham HospitalMary Newton Medical CenterBecky South Georgia Medical CenterPaulette University HospitalHeidi

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 24 Hearing from the experts.... Georgia’s LEAPT C diff prevention leaders What was your largest roadblock for achieving success in bundle implementation? What was your greatest success factor in your story? What “golden nuggets” could you share that you received during this project time that made the biggest difference in your allowing your hospital to make improvement strides? Could you share how your implementation of using front line staff in rapid cycle changes assisted in your improvements? 24

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 25 National LEAPT C diff Prevention Leaders 25 HEN NAME/TITLECONTACT Ascension HealthAnn Hendrich, RN, PhD, F.A.A.N. Senior Vice President, Chief Quality/Safety and Nursing Officer Georgia Hospital Association Research and Education Foundation (GA) Vi Naylor Executive Vice President Minnesota Hospital Association (MN) Tania Daniels, PT, MBA Vice President of Patient Safety Ohio Hospital Association (OH) Rosalie Weakland, RN, MSN, CPHQ, FACHE Senior Director of Quality Programs Washington State Hospital Association (WA) Carol Wagner, RN, MBA Senior Vice President Patient Safety

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 26 GAPP / LEAPT Updates/ Deadlines SPREAD OF LEAPT TOPICS July 3, 2014 CDI Coaching Call July 10, 2014 Sepsis Coaching Call Data Submission: – Due 3 rd or each month – send to Lynne Hall TOC (1 for sepsis and 1 for additional topic area) Checklist (1 per hospital) – Worker Safety Data (if in WS group) Send to Jean Allred due 15 th of month (about 45 days after end of reporting month). 26