1. GAPP Coaching Call C. difficile Prevention Working Session September 4, 2014 Jan Ratterree Lynne Hall Jean Allred

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 2 APIC Implementation Guide 2013 Guide to Preventing Clostridium difficile Infections http://www.apic.org/Resource_/EliminationGuideForm/59397f c6-3f90-43d1-9325-e8be75d86888/File/2013CDiffFinal.pdf http://www.apic.org/Resource_/EliminationGuideForm/59397f c6-3f90-43d1-9325-e8be75d86888/File/2013CDiffFinal.pdf 2

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3 Background Clostridium difficile, an anaerobic, Gram-positive,spore- forming bacillus, was first detected in 1935 in lower intestinal microbiota of healthy newborns. C. difficile was thought to be nonpathogenic for nearly four decades after its initial isolation It was only in 1978 that C.difficile was identified as the primary cause of pseudomembranous colitis in patients treated with antibiotics. 3

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 4 Pathogenesis and Changing Epidemiology of Clostridium difficile Infection (CDI) APIC Resource: Guide to Preventing Clostridium Difficile 2010 Clostridium difficile is spread via the fecal-oral route. – The organism is ingested either as the vegetative form or as hardy spores, which can survive for long periods in the environment and can traverse the acidic stomach. In the small intestine spores germinate into the vegetative form. In the large intestine, C difficile-associated disease can arise if the normal flora has been disrupted by antibiotic therapy. C. difficile reproduces in the intestinal crypts, releasing toxins A and B, causing severe inflammation. Mucous and cellular debris are expelled, leading to the formation of pseudomembranes. Toxin A attracts neutrophils and monocytes, and toxin B degraades the colonic epithelial cells, both leading to colitis, and water diarrhea. 4

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 5 Development of C. difficile Infection commonly has two essential requirements: (1) Exposure to antibiotics (2) New acquisition of C. difficile such as that occurring via fecal-oral transmission 5

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6 Acquisition.... Ingestion of spores.... – Contamination of the Environment – Shared contaminated Equipment – Hands of Healthcare / Others Hands Spores resist the acidity of the stomach and germinate into vegetative bacteria in the small intestine. Alteration of the normal lower intestinal microbiota by exposure to antibiotic provides an environment that allows C. difficile to multiply, flourish, and produce toxins that cause colitis. 6

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 7 Exposure Risk Changing Epidemiology Recent epidemiology evidence indicates patients remain at elevated risk for 3 or more months after they have stopped antibiotic treatment Emergency of CDI in populations previously thought to be at low risk, including severe cases among health peripartum women, and children and healthy people who have had minimal or no recent exposure to healthcare settings. 7

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 8 Take Aways... Check Points How are we doing individually / collaberatively Antibiotics – State of Georgia Antimicrobial Stewardship Honor Roll – Jeanne Negley DPH Contact (jenegley@dhr.state.ga.us) Exposure to Healthcare Environment – What are we doing with our EVS folks? – Next Steps.... Have we observed... Monitored for what we think is happening is really occurring 100% of the time Infection Prevention Practices – Hand Hygiene Isolation Precautions – Equipment Collaboration with our Partners/Physician Office Practices/Long Term Care/Infusion Centers????? 8

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 9 Diagnosis Who should be tested and how frequently State of Georgia CDI Testing Recommendations 9

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 10 Georgia Healthcare Associated Infections Advisory Committee Policy Statement: Laboratory Diagnosis of Clostridium difficile for Healthcare Facilities Issued: April 22, 2014 Based on strength of evidence, the Georgia Healthcare Associated Infections Advisory Committee makes the following recommendations for laboratory testing when Clostridium difficile is suspected. 1. The preferred testing method is nucleic acid amplification assay (includes polymerase chain reaction [PCR]). 2. An alternative testing method is a 2-step algorithm to detect common glucose dehydrogenase antigen (GDH) and Toxin A/B, with reflex to nucleic acid amplification assay for discrepant results. 3. Diagnostic tests that ONLY detect TOXINS by EIA should NOT be performed (sensitivity 63-94%, specificity 75- 100%). 4. Diagnostic tests should be performed ONLY on unformed, diarrheal stool specimens, except in the setting of ileus caused by Clostridium difficile 5. Repeat testing during the same episode of diarrhea is discouraged, particularly when a nucleic acid amplification assay is used. 6. Test of cure should NOT be performed as the assay may be positive after clinical cure. We encourage all healthcare facilities to have a written policy regarding laboratory diagnosis of Clostridium difficile. When possible, we encourage healthcare facilities to have a multidisciplinary committee to address all aspects of Clostridium difficile disease; at a minimum, this committee should include representation from infectious diseases, infection control, gastroenterology, microbiology, pharmacy, building management, and hospital administration. 10

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 11 Surveillance Acute Care Hospitals follow NHSN Lab ID C difficile Module Critical Access Hospitals not using NHSN should enter into the GHA Manual Data Entry Process using the below information beginning October 1, 2014 Numerator: –Hospital Onset – The number of C. difficile positive specimens in patients with specimen collection day beginning with > 3 days after admission to the facility (i.e., on or after day 4 with admission day being counted as Day 1). –Community Onset The number of C. difficile positive specimens in patients with specimen collection day beginning the day of hospital admission until day 3 (with admission day being day 1) Denominator: – Total number of Patient Days (do not count NICU and Well Baby) 11

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 12 NOVI reporting of C. difficile Begin surveillance/collection of data October 1 Place October data into GHA Manual Data Entry by November 15 th Contact Jan Ratterree with any questions related to data collection surveillance and/or reporting into NOVI – (770)-240-4518 – jratterree@gha.org 12

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 13 What is required in Manual Data Entry to obtain accurate data: Numerator: – The number of C. difficile positive specimens in patients with specimen collection day beginning with > 3 days after admission to the facility (i.e., on or after day 4). Important Numerator Definitions: – A + test for C. difficile is defined as: A positive laboratory test result for C. difficile toxin A and/or B, OR, A toxin-producing C. difficile organism detected by culture or other laboratory means performed on a stool sample. – Do not report a Duplicate toxin-positive laboratory (+) C. difficile toxin test result with prior (+) in ≤ 2 weeks in same patient and same location 13

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 14 What is required in NOVI to obtain accurate data: Denominator: – Total number of Patient Days (do not count NICU and Well Baby) – A daily count of the number of patients in the facility inpatient units during a time period. To calculate patient days, for each day of the month, at the same time each day, record the number of patients. At the end of the month, sum the daily counts and enter the total. – If patient days are available from electronic databases, these sources may be used as long as the counts are not substantially different (+/_5%) from manually-collected counts 14

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 15 What is required in NOVI to obtain accurate data: Denominator: – We are following inpatients A patient whose date of admission to the facility and the date of discharge are different calendar days. Note: A patient who is admitted to an inpatient location as an “observation” patient is identified as an inpatient on the first and subsequent days for the purposes of surveillance. 15

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 16 Case Study NHSN 2/1: 56 year old male admitted to facility with pneumonia. Central line inserted for antibiotics. 2/2: Patient voiding without difficulty. Cough with moderate sputum production. Patient complains of lower abdominal cramps, relieved with medication. 2/3: Patient begins to complain of worsening lower abdominal pain and now has a fever of 38.2. BM with loose unformed stool. 2/4: While on 2E, the patient continues to complain of lower abdominal pain and loose stools. Over the course of 24 hours, the patient had three loose stools. Unformed stool specimen collected and sent for testing (This is day 4) 2/5: Lab results identified toxin positive C. difficile toxin samples. 16

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 17 Other details... This is a c diff lab event that would be entered into data. Count total number of events and submit as numerator Count total number of patient days and submit as denominator Do not count Emergency Department encounters in your denominator “Observation” patients placed on your unit who have an overnight stay are counted as inpatient days. 17

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 18 Best Practice Snapshot C difficile Prevention 18 Best Practice Survey Results August 2014 YesNoYes%No% 1. In your facility, are patients with C. difficile placed on Contact Precautions?1000100%0% 2. Is hand hygiene with soap and water required after caring for patients with C. difficile infection?98298%2% 3. Does your lab have a rejection policy for testing formed stools for C. difficile?752575%25% 4. Is a bleach-product used for environmental disinfection for C. difficile patients at your facility?97397%3% 5. Does your facility have a specific person (or people) responsible for reviewing antibiotic utilization with the goal of promoting the judicious use of antimicrobial agents?821882%18% 6. Does your facility currently restrict the use of any antibiotic?495149%51% 7. Is surveillance for C. difficile infection performed in your facility?92892%8%

19. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 19 Success.... Share our Success Stories Share our Roadblocks Share next steps.... How do we Improve???? 19

20. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 20 RCA Individual Events 20 Event #Adm.DateRoom #Order DateSpecimen Collected DateSymptoms documentedOn Antibiotic Y/ND/C wi 2 weeks Tx from LTC

21. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 21 GAPP Updates Mandatory Meeting Attendance – Coaching Call and Sepsis Discussion Second Thursday of month. Must complete an evaluation – If you miss a call you can listen to the recording within 1 week. Complete evaluation if applicable, and notify topic lead that you listened to get credit. Data Submission: – Due 3 rd or each month – send to Lynne Hall (lhall@gha.org)lhall@gha.org 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 (jallred@gha.org)jallred@gha.org due 15 th of month (about 45 days after end of reporting month). Next Coaching Call National Sepsis Recognition Speaker: Tammy Gilliland September 11, 1 - 2 pm Please make every effort to attend and invite your Sepsis Team to listen 21