C. diff toolkit by Rosemary Hicks

Clostridium difficile Change Package

Table of Contents Disclaimer............................................................................................................................. 4 Introduction Clostridium difficile Overview (what is C diff)........................................................ 5 CDCâ&#x20AC;&#x2122;s FAQ about C. diff......................................................................................... 6 FAQs about the Virginia Make a Difference C diff Collaborative............................ 8 Surveillance of Clostridium difficile Definition 1. Acute Care Webinar reporting in NHSN................................................................................... 12 NHSN C. difficile Reporting..................................................................................... 13 Using NHSN for CDI LabID Reporting to CMS......................................................... 42 C. diff Surveillance and Prevention Resources....................................................... 48 C.difficile Surveillance algorithm for rapid identification and isolation................. 45 1. Nursing Homes Webinars................................................................................................................ 46 Handouts................................................................................................................ 46 C.difficile Infection Surveillance log....................................................................... 47 C. diff Surveillance and Prevention Resources....................................................... 48 C.difficile Surveillance algorithm for rapid identification and isolation................. 45 Hand hygiene Rational for Hand Hygiene â&#x20AC;&#x201C; C. diff........................................................................ 50 Hand hygiene for healthcare care workers............................................................ 51 Signs Contact Plus Precaution Sign.................................................................................. 61 Contact precautions specific to Clostridium difficile sign....................................... 63 Help Prevent the Spread of Infection..................................................................... 64 Environmental cleaning of Clostridium difficile C. diff Surveillance and Prevention Resources (not just a maid service)................ 66 Cleaning Pocket Card.............................................................................................. 67 Environmental Cleaning......................................................................................... 69

Antibiotic stewardship VHQC VDH Webinar............................................................................................... 94 Antibiotic Stewardship Resources.......................................................................... 95 Education on Clostridium difficile Presentation- Kerkering webinar Q&A- for physicians and APN (advanced practice nurses/ PAâ&#x20AC;&#x2122;s)............................................................................ 96 C. diff staff educations guide with post test .......................................................... 130 Environmental Cleaning......................................................................................... 69 Hand hygiene for healthcare care workers............................................................ 51 Patient/ Resident/ Family Education booklet trifold.............................................. 154 Patient/Resident/Family Education Flyer............................................................... 156 Resources C. diff Surveillance and Prevention Resources....................................................... 48 Antibiotic Stewardship Resources.......................................................................... 95

Disclaimer The documents in this change package were developed by the contributors to the Virginia Make a Difference C. diff collaborative in fall 2012 and spring 2013. The aim of this toolkit is to assist facilities in reducing C. difficile by implementing best practices, providing education and tools aimed at increasing communication across the healthcare spectrum. The work was guided by the best available evidence at the time this toolkit was created. The toolkit responds to the challenges facilities face as they translate guidelines into practice. Additionally, this toolkit relays the objectives of Virginia Make a Difference C. diff collaborative that are directed at providing access to additional resources for healthcare facilities, creating a repository of information and constructing a toolkit of strategies that will assist facilities with educating patients, staff and families about C. diff prevention. Contributors to this toolkit include: Augusta Health William Cohee, Pharm D Clint Merritt, MD Carolyn Palmer, RN Augusta Nursing and Rehabilitation Center Karen Riley, MSN, RN-BC, LNHA Carilion New River Valley Medical Center Betsy Allbee, RN, BSN, CIC Centra Health Kathy Bailey, RN, CIC VHQC Sandra Gaskins, RHIT Amy Lenz, BS Jennifer Reece, RN, MSN, CIC Deborah Smith, RN, BSN, CIC Virginia Department of Health Andrea Alvarez, MPH Carol Jamerson, RN, BSN, CIC Virginia Tech Carilion School of Medicine and Carilion Clinic Thomas Kerkering, MD, FACP, FIDSA

Clostridium difficile Overview What is it? Clostridium difficile [pronounced Klo-STRID-ee-um dif-uh-SEEL], also known as “C. diff” or “C. difficile”, is a bacteria that can affect the digestive system and is able to produce spores. Most cases of C. diff infection (or CDI) occur in patients that are currently taking or have recently taken antibiotics. Individuals at a higher risk for infection include the elderly, those with weakened immune systems or severe underlying illness, and patients who have spent long periods of time in healthcare facilities.

What are the Symptoms? Many people carry C. diff germs in their bodies without any symptoms. This is called being “colonized”. A person may be colonized for a long time before getting sick or may never get sick. The most common symptoms of a C. diff infection include watery diarrhea, fever, loss of appetite, nausea, and stomach pain and tenderness. More serious infections can also develop in the intestine.

How is it spread? C. diff is shed in feces (stool). Any surface, device, or material (e.g., toilets, bathtubs, thermometers) that becomes contaminated with feces may serve as a reservoir for the C. diff spores. C. diff spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. C. diff can live for long periods on surfaces.

How is it treated? A mild C. diff infection can usually be controlled by stopping the antibiotic(s) the patient is taking. Other infections may be treated with a more powerful and appropriately targeted antibiotic. Sometimes, symptoms may return after treatment. This is called a relapse, and occurs in about 1 in 4 patients with C. diff. Some patients have multiple relapses. In some severe cases (approximately 1-2 out of every 100), a person might have to have surgery to remove the infected part of the intestine. Cases of C. diff – especially when they occur in people who were already very ill – can be fatal.

How is it prevented? • C. diff can spread very easily and live on surfaces for a long time. Despite this, there are some things healthcare providers can do to prevent transmission: • Practice good hand hygiene. Follow your facility’s hand hygiene policy to clean hands with soap and water or in some instances, an alcohol-based hand rub, before and after caring for every patient. (Note that alcohol-based hand rubs are not as effective against spore-forming bacteria such as C. diff and their use is not recommended during outbreaks or if the facility is having a problem with ongoing transmission). • Use antibiotics judiciously – prescribe antibiotics with the appropriate spectrum, duration, and dose. • Carefully clean and disinfect rooms of patients with C. diff with your healthcare facility’s EPA-approved sporicidal or with a product containing bleach. • Use Contact Precautions when caring for patients with C. diff to prevent the bacteria from spreading to others. This means: § Healthcare providers (and visitors) clean their hands and put on gloves and wear a gown over their clothing when taking care of or visiting a person with C. diff. § When leaving the room, healthcare workers and visitors remove their gown and gloves and clean their hands. § Whenever possible: o Assign patients with C. diff to a private room with a private bathroom. o Dedicate medical equipment to a single patient with C. diff. If reusable equipment must be used, clean and disinfect between patients.

FAQS about Clostridium difficile What is Clostridium difficile infection? Clostridium difficile [pronounced Klo-STRID-ee-um dif-uh-SEEL], also known as “C. diff” [See-dif], is a germ that can cause diarrhea. Most cases of C. diff infection occur in patients taking antibiotics. The most common symptoms of a C. diff infection include: Watery diarrhea Fever Loss of appetite Nausea Belly pain and tenderness

Who is most likely to get C. diff infection? The elderly and people with certain medical problems have the greatest chance of getting C. diff. C. diff spores can live outside the human body for a very long time and may be found on things in the environment such as bed linens, bed rails, bathroom fixtures, and medical equipment. C. diff infection can spread from person-toperson on contaminated equipment and on the hands of doctors, nurses, other healthcare providers and visitors.

Can C. diff infection be treated? Yes, there are antibiotics that can be used to treat C. diff. In some severe cases, a person might have to have surgery to remove the infected part of the intestines. This surgery is needed in only 1 or 2 out of every 100 persons with C. diff.

What are some of the things that hospitals are doing to prevent C. diff infections? To prevent C. diff. infections, doctors, nurses, and other healthcare providers: • Clean their hands with soap and water or an alcohol-based hand rub before and after caring for every patient. This can prevent C. diff and other germs from being passed from one patient to another on their hands. • Carefully clean hospital rooms and medical equipment that have been used for patients with C. diff. • Use Contact Precautions to prevent C. diff from spreading to other patients. Contact Precautions mean: o Whenever possible, patients with C. diff will have a single room or share a room only with someone else who also has C. diff. o Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with C. diff. o Visitors may also be asked to wear a gown and gloves. o When leaving the room, hospital providers and visitors remove their gown and gloves and clean their hands. o Patients on Contact Precautions are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They can go to other areas of the hospital for treatments and tests. • Only give patients antibiotics when it is necessary.

What can I do to help prevent C. diff infections?

• Make sure that all doctors, nurses, and other healthcare providers clean their hands with soap and water or an alcohol-based hand rub before and after caring for you. • If you do not see your providers clean their hands, please ask them to do so. • Only take antibiotics as prescribed by your doctor. • Be sure to clean your own hands often, especially after using the bathroom and before eating.

Can my friends and family get C. diff when they visit me? • C. diff infection usually does not occur in persons who are not taking antibiotics. Visitors are not likely to get C. diff. Still, to make it safer for visitors, they should: • Clean their hands before they enter your room and as they leave your room • Ask the nurse if they need to wear protective gowns and gloves when they visit you.

What do I need to do when I go home from the hospital? Once you are back at home, you can return to your normal routine. Often, the diarrhea will be better or completely gone before you go home. This makes giving C. diff to other people much less likely. There are a few things you should do, however, to lower the chances of developing C. diff infection again or of spreading it to others. • If you are given a prescription to treat C. diff, take the medicine exactly as prescribed by your doctor and pharmacist. Do not take half-doses or stop before you run out. • Wash your hands often, especially after going to the bathroom and before preparing food. • People who live with you should wash their hands often as well. • If you develop more diarrhea after you get home, tell your doctor immediately. • Your doctor may give you additional instructions. If you have questions, please ask your doctor or nurse.

FAQS

about the Virginia Make a Difference C. diff Collaborative

1. What is the Virginia Make a Difference C. diff collaborative? Providers across the state of Virginia have joined a campaign to concentrate on Clostridium difficile (C. diff) prevention and minimize death, disability, and healthcare-associated costs resulting from C. diff infection by educating healthcare workers, patients, and the public at large, and by implementing standardized surveillance practices and evidence-based prevention strategies. The Virginia Make a Difference C. diff collaborative is being led by VHQC and the Virginia Department of Health to promote best practices such as prescribing antibiotics responsibly, implementing evidence-based infection prevention methods, and extending C. diff prevention programs across the healthcare spectrum, from acute care to long-term care. The Virginia C. diff collaborative will emphasize enhanced communication between healthcare entities, healthcare providers, and patients and their families.

2. What is the goal of the collaborative? The ultimate goal is to reduce Clostridium difficile infection (CDI) in Virginia. The aim of the collaborative is to reduce C. diff rates by 15% by utilizing evidence-based methodologies including rapid identification and isolation of C. diff infections, enhanced hand hygiene, environmental cleaning, and antibiotic stewardship.

3. Is participation in the collaborative mandatory? Participation in the Virginia Make a Difference C. diff collaborative is voluntary. A coordinated, statewide effort is the most effective and successful approach to having a positive impact on infection prevention strategies. This approach is more effective and cohesive than creating or remodeling similar improvement projects.

4. What benefits could a facility gain from joining The Virginia Make a Difference C. diff collaborative? Participants will have the opportunity to share and spread lessons learned from their colleagues and peers across the state as evidence-based C. diff prevention practices are presented through webinars and conference calls. Additionally, free resources, tools and consultation will be available for Infection Prevention and Quality Improvement professionals. Evidence-based best practices to promote and strengthen communication between facilities will include: â&#x20AC;˘ Providing education to patients/residents/family members and/or healthcare providers about topics such as: o Hand hygiene o C. diff spread and survival in the healthcare environment and on surfaces o Patient and/or healthcare worker transmission and/or acquisition of C. diff from contact with contaminated surfaces o Transmission via the fecal-oral route o Daily and terminal cleaning of the patient/resident environment â&#x20AC;˘ Evidence-based prevention methodologies will include: o Incorporating bundle practices, including early detection through appropriate surveillance case-finding methods and microbiologic identification o Implementing contact precautions, and appropriate patient/resident placement o Establishing and monitoring adherence to environmental cleaning and disinfection strategies o Monitoring adherence to hand hygiene

o Implementing antibiotic stewardship strategies o Developing and disseminating tools: surveillance documents, checklists, staff and patient education materials, etc. to support actions. o Utilizing teams to lead prevention and treatment efforts. o Conducting surveillance to quantify the burden of C. diff infections in participating facilities and measuring improvement over the duration of the project.

5. Why is Virginia focusing on C. diff? According to the Centers for Disease Control and Prevention (CDC), from 2000 to 2009, the number of hospitalized patients with any C. diff discharge diagnosis more than doubled, from approximately 139,000 to 336,600. The number of patients with a primary C. diff diagnosis more than tripled, increasing from 33,000 to 111,000. Nationally, an estimated 14,000 deaths are linked to C. diff each year, with at least $1 billion in C. diff related healthcare costs. The national trends extend to the state level. From 2000 to 2009, the annual rate of hospitalization for C. diff has more than tripled from nine to 29 per 100,000 Virginians. In 2009, the average Virginia hospital costs for patients with C. diff was $23,190, compared to $8,860 for patients without C. diff.

6. What are the benefit of hospitals and nursing homes working together in the Virginia Make a Difference C. diff collaborative? Across the state, hospitals and nursing homes share clients. The collaborative will assist facilities to standardize C. diffÂ surveillance methods using a common definition, promote best practices such as prescribing antibiotics responsibly, implement evidence-based infection prevention methods, and emphasize enhanced communication between healthcare entities, healthcare providers, patients, and families.

7. What definition of C. diff will the collaborative facilities be using? Collaborative facilities will be using National Healthcare Safety Network (NHSN) definitions for C. difficile and conducting surveillance facilitywide. Acute care facilities will be using the LabID definition, which is: â&#x20AC;˘ A positive laboratory test result for C. difficile toxin A and/or B, (includes molecular assays [PCR] and/or toxin assays) or â&#x20AC;˘ A toxin-producing C. difficile organism detected by culture or other laboratory means performed on a stool sample. All non-duplicate C. difficile toxin-positive laboratory results are considered a LabID event. LabID events can include specimens collected in the Emergency Department of the admitting facility or other affiliated outpatient location, if collected the same calendar day as patient admission. Duplicate C. difficile-positive test: Any C. difficile toxin-positive laboratory result from the same patient and location, following a previous C. difficile toxin-positive laboratory result within the past two weeks (14 days) (even across calendar months). There should be a full 14 days with no C. difficile toxin-positive laboratory result for the patient and location, before another C. difficile LabID event is entered into NHSN for the patient and location. The date of specimen collection is considered Day 1.

Long-term care facilities will be using a similar definition that requires a clinical and laboratory component: • Clinical component o 3 or more liquid or watery stools above what is normal for the resident within 24 hours or

o Presence of toxic megacolon (abnormal dilatation of the large bowel, documented radiologically) AND

• Laboratory component o Stool sample positive for C. diff (either by an assay for Toxins A and/or B, by culture, or by other means) and/or

o Evidence of pseudomembranous colitis detected during endoscopic examination or surgery or on histopathologic examination of a biopsy specimen

When determining C. diff rates, the numerator will be defined as the number of non-duplicate C. difficile LabID events for the facility during the specified month that meet the CDC/NHSN definition. The denominator will be patient days (acute care) or resident days (long-term care) for the facility for that month (excluding any neonatal intensive care units, specialty care nursing units, or well-baby locations).

8. What is required of facilities for full participation in the Virginia Make a Difference C. diff collaborative? Acute Care • Submit monthly surveillance data to NHSN no later than 45 days after the close of the month. • Confer rights to VHQC and the National Coordinating Center (NCC). As a user of the VHQC C. diff collaborative group, VDH will also have rights to these data. o Baseline period: Dec 2012 – Feb 2013 o Project period: Mar 2013 – Aug 2013 o However, retrospective data from July- November 2012 is encouraged Long-Term Care • Submit monthly surveillance log to VHQC no later than 45 days after the close of the month. o Baseline period: Dec 2012 – Feb 2013 o Project period: Mar 2013 – Aug 2013

9. Are my data secured? VHQC, NCC, and VDH maintain the strictest confidentiality and security with your data. All data will be de-identified and aggregated to measure improvement rates only. For example, aggregated C. diff incidence rates may be shared with the participating facilities to track progress toward the collaborative’s goals.

10. Is there a cost to participate? Direct costs: • There are no direct joining costs • Other material costs such as paper, copying, communication materials as needed/ desired • Salary costs for employees performing C. diff surveillance

Indirect costs: • Time required to communicate organizational commitment to and participation in the collaborative to employees/ peers • Time commitment to collaborative and team meetings to include duties such as planning, implementing evidenced based strategies, and evaluating progress • Participation in statewide webinars and conference calls

11. What is the leadership involvement? As with any successful improvement initiative, it is important to engage leadership to be a part of your improvement team and garner their support. Leadership buy-in assures that your collaborative team will have the supplies, staff, materials, and time to affect change in the facility. They should receive updates on the status of the project and ensure that that administrative or systems issues do not pose barriers to the success of your surveillance and prevention activities. With leadership/executive-level participation, your staff and other members of your collaborative team will see and know that the facility leadership is dedicated to quality and patient safety.

NHSN C. Difficile Reporting Webinar

www.vhqc.org/docs/November_CDIFF.pdf

Kathy Bailey, RN, CIC Centra Health

Obj i Objectives y Discuss components and requirements d

for C. difficile reporting y Describe pros and cons for collecting C. difficile labID events y Identify processes to collect data y Define methods to utilize data

January 2013 CMS Reporting Requirement January 2013 CMS Reporting Requirement C. difficile (CDI) LabID event y Acute care hospitals y Facility wide reporting – NHSN has confirmed this expectation to include facility wide i inpatient reporting i.e. C. difficile positive i i i C diffi il ii findings from all inpatient locations (exceptions: neonatal intensive care units (exceptions: neonatal intensive care units, well baby nurseries, and well baby clinics)

Pros and Cons of CDI LabID Reporting Pros and Cons of CDI LabID Reporting Pros y Not as labor intensive as other reporting requirements y Only required to report CDI by lab result and patient y q p y p location Cons y Time commitment estimated to be 2 hours/week Ti i i d b h / k WITH a good lab reporting system and an electronic medical record y Limited value because data is not being generated by NHSN definition (clinical findings) but “by proxy‐ solel on lab data and limited admission data” solely on lab data and limited admission data 16

Needs List for C. difficile NHSN Reporting y Daily listing of inpatient C. difficile positive findings y Means to identify:

1) duplicate reporting – defined as same patient AND SAME LOCATION within the previous 14 days ‐ “there should be a full 14 days with no C there should be a full 14 days with no C. difficile toxin‐ difficile toxin positive result for the patient and location before another C. difficile LabID event is entered”

2) location (nursing unit) of patient when testing was performed and date admitted to that unit 3) whether or not the patient was in your facility within the l t last 3 months and date of any prior admission within 3 th d d t f i d i i ithi months 4) total inpatient days and number of inpatient admissions/month (excluding NICU and newborn nurseries) 5) time to get this done! 17

Other Definitions y CDI‐positive laboratory assay:

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. – only on only on “unformed (i unformed (i.e. conforming to the shape of the e conforming to the shape of the container) stool samples”

y Admission dates:

When determining a patient’s admission dates to both the facility and specific inpatient location, take into account all such days, including any days spent in an inpatient location as an “observation” patient, as these days contribute to exposure “ b i ” i h d ib risk. For further information on counting patient days and F f th i f ti ti ti t d d admissions, go to:

http://www.cdc.gov/nhsn/PDFs/PatientDay_SumData_Guide.pdf for Summary 19

NHSN Categorization of CDI LabID Events S Catego at o o C ab e ts (Based only on lab findings, dates, and locations) y Community‐Onset (CO): LabID Event

collected ≤ 3 days after admission to the facility (i e days 1 2 or 3 of admission) facility (i.e., days 1, 2, or 3 of admission). y Community‐Onset Healthcare Facility‐ Associated (CO‐HCFA): CO LabID Event ( ) collected from a patient who was discharged from the facility ≤ 4 weeks prior to current date of stool specimen collection date of stool specimen collection. y Healthcare Facility‐Onset (HO): LabID Event collected > 3 days after admission to the 3 y facility (i.e., on or after day 4). 20

Updating the Monthly Reporting Plan

You previously added CLABSI, colon and abd hyst procedures here

Choose FacilityWideIN CDIF Lab ID event

Entering Inpatient Locations

Add All Inpatient Locations

You previously added critical care units here

NHSN inpatient location listing

Examples from Centra’s Inpatient Listing

Entering a CDI LabID Event

Note required fields (*) q ( )

P Preâ&#x20AC;?populated l d

DenominatorÂ Data

Denominator Data Remember to exclude your NICU and nursery patient day and admission data

Analysis

Calculated CDI Rates Available via NHSN Admission Prevalence Rate = Number of non‐duplicate CDI LabID Events per patient per month identified ≤ 3 days after admission to the facility / Number of patient admissions to the facility x 100 Location Percent Admission Prevalence that is Community‐Onset = Number of Admission Prevalent LabID Events to a location that is CO / Total number Admission Prevalent LabID Events x 100 (Note: The numerator in this formula does not include Admission Prevalent LabID Events that are CO‐HFCA.) Location Percent Admission Prevalence that is Community‐Onset Healthcare Facility‐Associated = Number of Admission Prevalent LabID Events to a location that are CO‐ HCFA / Total number Admission Prevalent LabID Events x 100 Location Percent Admission Prevalence that is Healthcare Facility‐Onset = Number of Admission Prevalent LabID Events to a location that are HO / Total number of Admission Prevalent LabID Events x 100 34

Calculated CDI Rates Available via NHSN ll l Overall Patient Prevalence Rate = Number of 1st CDI LabID Events per patient per month regardless of time spent in facility (i.e., CO + CO‐HCFA + HO, if monitoring by overall facility‐wide inpatient FacWideIN) / Number of patient admissions to the location or inpatient=FacWideIN) / Number of patient admissions to the location or facility x 100 Location CDI Incidence Rate = N Number of Incident CDI LabID Events per month identified > 3 days after b f I id t CDI L bID E t th id tifi d d ft admission to the location / Number of patient days for the location x 10,000 Facility CDI Healthcare Facility‐Onset Incidence Rate = y y Number of all Incident HO CDI LabID Events per month in the facility/ Number of patient days for the facility x 10,000 (this calculation is only accurate for Overall Facility‐wide Inpatient reporting) Facility CDI Combined Incidence Rate = Number of all Incident HO and CO‐HCFA CDI LabID Events per month in the facility / Number of patient days for the facility x 10,000 (this calculation is only accurate for Overall Facility‐wide Inpatient reporting) **Line listing option also available** 35

Li Li ti E Line Listing Example l

Using NHSN for Clostridium difficile Infection (CDI) Laboratory-Identified (LabID) Event Reporting via NHSN for Compliance with CMS Reporting Requirements Nov 2012 Purpose:

To calculate proxy measures of C. difficile infections (CDI), exposure burdens, and healthcare acquisitions through monitoring and reporting data from positive clinical cultures (unformed stool only).

Table 1. Centers for Medicare and Medicaid Services (CMS) 2013 C. difficile LabID Event Reporting Requirement:

Organism:

Clostridium difficile (C.diff)

Data collection/reporting mechanism: Required locations:

CDC NHSN (National Healthcare Safety Network) – MDRO/CDI Module (LabID Event)

Required data:

All C. difficile LabID Events on unformed stool specimens at the facility-wide inpatient level

Start date:

January 2013

All inpatient locations at Facility-wide Inpatient level (FacWideIN), minus neonatal intensive care (NICU), and Well Baby locations [e.g., Well Baby Nurseries, Well Baby Clinics, babies in Labor/Delivery/Recovery/Postpartum (LDRP)]

What Data Will Be Reported to CMS: CDI; all non-duplicate, non-recurrent LabID Event specimens collected >3 days after admission to the facility. Creating a Monthly Reporting Plan: CDI Events must be included in Monthly Reporting Plan each month for data to be reported on behalf of the facility to CMS.

CMS requirement is facility-wide inpatient reporting.

Facility-wide Inpatient (FacWideIN): Includes all inpatient locations, including observation patients housed in an inpatient location. Assess Whether You Need to Add Locations for NHSN Reporting: If you have only been reporting ICU-related CLABSI and CAUTI (as currently required), you will need to map your entire facility and add other locations into NHSN in order to report facility-wide inpatient C. difficile appropriately.

Add all inpatient locations before reporting begins in 2013. Each LabID Event (numerator) is reported according to the patient’s location when the stool specimen is collected. This means that any inpatient unit (except for the locations referenced in Table 1) could potentially house a patient who has a C. difficile LabID Event.

To Add a Location: NHSN Patient Safety Component Home Page

Facility

Locations · Add the locations (includes the Unit “code”(e.g., “SCU” for Surgical Care Unit), the unit “label” (or name), the “CDC location description” (e.g., inpatient medical ward), the “Status” (active), and the “Bed Size” (# beds on the unit) .Click “Add” after each location is added.

Reporting Requirements and Options: Active participants must choose main reporting method: o Infection Surveillance (optional)

o LabID Event Reporting (required by CMS January 2013) Important Dates: Data must be submitted monthly (within 30 days of the end of the month which is collected).

For data to be shared with CMS, each quarter’s data must be entered into NHSN no later than 4 ½ months after the end of the quarter.

Table 2. NHSN Data Due Dates for CMS Quarter 1 2 3 4

Data Months Jan – Mar Apr – Jun Jul – Sept Oct – Dec

Due to NHSN* August 15 November 15 February 15 May 15

* NHSN data will be frozen at 00.00 on the 16th

Definitions: CDI Positive Laboratory Assay: · 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 [remember, C. difficile testing should be only done on unformed stool samples (should conform to shape of container)] Duplicate C. difficile Positive Test: Any C. difficile toxin-positive laboratory result from the same patient and same location, following a previous C. difficile toxin-positive laboratory result with the past 14 days. Non-duplicate LabID Event: A toxin-positive C. difficile stool specimen for a patient in a location with no prior C. difficile specimen result reported within 14 days for the patient and location. LabID Event: A laboratory-identified event. A toxin-positive/ toxin-producing C. difficile stool specimen for a patient in a location with no prior C. difficile specimen reported within 14 days for the patient and location and having a full 14-day interval with no toxin-positive C. difficile stool specimen identified by the lab since the prior reported C. difficile LabID Event. Also referred to as non-duplicate C. difficile toxin-positive laboratory result.

Lab ID Events never include results from Active Surveillance Testing.

CDI Infection Surveillance Definition: C. difficile is identified as the associated pathogen for LabID Event or HAI reporting (Gastrointestinal System Infection (GI)-Gastroenteritis (GE) or Gastrointestinal Tract (GIT).

Will the LabID Events Be Categorized as Community-Onset or Healthcare Facility Onset?

NHSN will categorize CDI LabID Events based on Inpatient Admissions and specimen collection dates o Healthcare-facility onset (HO):

LabID Event specimen collected > 3days after admission to the facility (i.e., on or after day 4)

o Community-Onset (CO):

LabID Event specimen collected as an inpatient < 3 days after admission to the facility (i.e., days 1 (admission), 2, or 3)

o Community-Onset Healthcare Facility-Associated (CO-HCFA):

CO LabID Event collected from a patient who was discharged from the facility < 4 weeks prior to the date current stool specimen was collected.

NHSN will further categorize CDI LabID Events based on specimen collection date and prior specimen collection date of a previous CDI LabID Event (that was entered into NHSN): o Incident CDI Assay:

Any CDI LabID Event from a specimen obtained > 8 weeks after the most recent CDI LabID Event (or with no previous CDI LabID Event documented) for that patient.

o Recurrent CDI Assay:

Any CDI LabID Event from a specimen obtained > 2 weeks and < 8 weeks after the most recent CDI LabID Event for that patient.

This material was prepared by VHQC, the Medicare Quality Improvement Organization for Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. VHQC/IIPC/1/14/2013/1528

Clostridium difficile (C. diff) Isolation Algorithm Clostridium difficile (C. diff) Isolation Algorithm Suspicion of C. diff based on the following symptoms: • 3 or more* loose, watery stools within 24 hours, not related to a laxative bowel prep *Above resident’s baseline, if long-‐term care • No stool in the presence of an ileus • Elevated WBC • +/-‐ exposure to antibiotics Consider other infectious or Implement Transmission-‐Based non-‐infectious diarrheal Precautions diseases • Gloves and gowns upon room Maintain Standard Precautions entry • Practice enhanced hand hygiene • Continue t o m onitor stools per facility’s C. diff policy • Practice good hand hygiene, • Send 1 liquid (unformed) stool YES NO per policy specimen for C. diff testing • Manage and clean patient • Clean patient care equipment care equipment and and environment with bleach environment per policy solution or sporidicial agent per policy

Positive C. diff test

• • •

Negative C. diff test

Continue Transmission-‐Based Precautions Notify infection preventionist and physician Provide education to patient and any visitors DO NOT RETEST and DO NOT send additional stool specimens for testing When diarrhea stops (stools are formed x 3), consider continuing transmission-‐based precautions for an additional 48 hours, especially in an outbreak situation or when ongoing transmission is suspected

Nursing Home Webinars & Transcripts to view an up to date list of all of the webinars and transcripts posted on our website visit: www.vhqc.org/qio/resources and look under C.Diff Collaborative

Biofilm and Recommended Cleaning (June 2013) click here to view this webinar click here to view this transcript

Transmission-based Precautions and Hand Hygiene (May 2013) click here to view this webinar click here to view this transcript

Environmental Cleaning (March 2013) click here to view this webinar click here to view this transcript

Antimicrobial Stewardship: Practical Strategies for the Healthcare Team (February 2013) click here to view this webinar click here to view this transcript

Surveillance and Reporting (January 2013) click here to view this webinar click here to view this transcript

C.difficile Infection Surveillance log C. diﬃcile Surveillance Log

Facility __________________________________ Month/year ____________________

Place Total # of C. diff LabID Events in beige box

Place Total # of Resident Days in green box

Facility CDI rate per 10,000 patient/resident days #DIV/0!

Resident Identifier (e.g., MRN)

Admission Date (MM/DD/YY)

Date of Positive C. diff Test (MM/DD/YY)

Test Type* (1,2,3,4)

Previous Positive C. diff Test (Y/N)

If Y, Date of Most Recent Previous Positive

LabID Event** (Y/N)

* Test Type: 1 = Stool culture / 2 = PCR assay / 3 = Antigen test / 4 = Enzyme immunoassay (EIA) ** LabID Event = If no previous positive C. diff test or prior positive > 14 days from current positive, LabID = Y This material was prepared by VHQC, the Medicare Quality Improvement Organization for Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. VHQC/ IIPC/11/26/2012/1490

C. difficile Surveillance and Prevention Resources VHQC/VDH C. difficile Infection Prevention Collaborative Guidelines and Recommendations: • American Academy of Pediatrics Policy Statement. Clostridium difficile Infection in Adults and Children. Pediatrics. 2013;131(1):196-200. http://pediatrics.aappublications.org/content/131/1/196.full

• APIC Implementation Guide: Guide to Preventing C. difficile Infections. February 2013.

http://apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d1-9325-e8be75d86888/File/2013CDiffFinal.pdf

• Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). http://www.cdc.gov/HAI/pdfs/cdiff/Cohen-IDSA-SHEA-CDI-guidelines-2010.pdf

• Dubberke ER, Gerding DN. Rationale for Hand Hygiene Recommendations after Caring for a Patient with Clostridium difficile Infection, Fall 2011. http://www.shea-online.org/Portals/0/CDI%20hand%20hygiene%20Update.pdf

• Rutala WA, Weber DJ, et al., and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf

• SHEA/IDSA Compendium of Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals, 2008. http://www.jstor.org/stable/10.1086/591065

• Siegel JD, Rhinehart E, Jackson M, Chiarello L, et al. The Healthcare Infection Control Practices Advisory Committee (HICPAC). 2007 Guideline for Isolations Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html

CDC: • C. difficile website •

Home page: http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html

•

Facility prevention tools: http://www.cdc.gov/hai/organisms/cdiff/Cdiff_settings.html

•

CDC Vital Signs: Making Health Care Safer: Stopping C. difficile Infections. March 2012.

•

National Healthcare Safety Network (NHSN) Multidrug-resistant Organism and Clostridium difficile Infection (MDRO/CDI) Module

http://www.cdc.gov/VitalSigns/Hai/StoppingCdifficile/

http://www.cdc.gov/nhsn/acute-care-hospital/cdiff-mrsa/index.html

VHQC and Virginia Department of Health: • VDH C. difficile website http://www.vdh.virginia.gov/epidemiology/surveillance/hai/cdiff.htm

• VHQC C. difficile collaborative resources http://www.vhqc.org/qio/resources

Other Resources: • Agency for Healthcare Research and Quality (AHRQ) Evaluation and Research on Antimicrobial Stewardship’s Effect on Clostridium difficile (ERASE C. difficile) Project: Tookit for Reduction of Clostridium difficile Through Antimicrobial Stewardship. September 2012. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/cdifftoolkit/cdifftoolkit.pdf

• Illinois Department of Public Health Environmental Cleaning Resource: “Not Just A Maid Service” •

www.notjustamaidservice.com/

•

www.youtube.com/notjustamaidservice

• SHEA Patient Education Guide (C. diff) http://www.shea-online.org/Assets/files/patient%20guides/NNL_C-Diff.pdf

• SHEA Position Paper: Clostridium difficile in Long-Term–Care Facilities for the Elderly, 2002 http://www.shea-online.org/Assets/files/position_papers/SHEA_Cdiff.pdf • Virginia Health Information (VHI): “Clostridium difficile (C. difficile) Dodging a One-Two Punch” (educational flyer) http://www.vhi.org/guides_cdiff.asp

Other States: Arizona: C. difficile collaborative toolkit http://azdhs.gov/phs/oids/hai/documents/HAIcommittee/cdiff-prevention-toolkit.pdf

Florida: C. difficile collaborative toolkit http://www.doh.state.fl.us/disease_ctrl/epi/HAI/CDI.html

Illinois: C. difficile collaborative information http://www.idph.state.il.us/patientsafety/ice_home.htm

New York: C. difficile collaborative toolkit http://www.gnyha.org/7925/Default.aspx

Note: For more information on antibiotic stewardship resources, please see the “Antibiotic Stewardship Resources: VHQC/VDH C. difficile Infection Prevention Collaborative” document also included in the collaborative change package

A Compendium of Strategies to Prevent HealthcareAssociated Infections in Acute Care Hospitals Fall 2011 Update

Rationale for Hand Hygiene Recommendations after Caring for a Patient with Clostridium difficile Infection Erik R. Dubberke, MD, MSPH; Dale N. Gerding, MD

Questions frequently arise in regards to the recommended method of hand hygiene after caring for patients with Clostridium difficile infection (CDI). The CDI component of the SHEA / IDSA Compendium of Practice Recommendations to Prevent Healthcare-Associated Infections and the SHEA / IDSA Clinical Practice Guidelines for CDI recommend preferential use of soap and water for hand hygiene over alcohol-based hand hygiene products only in outbreak settings (BIII) (1;2). Some have found the recommendation to preferentially perform hand hygiene with soap and water after caring for a patient with CDI only during outbreaks, and not in non-outbreak settings, confusing. Alcohol does not kill C. difficile spores (1). In addition, several studies have found hand washing with soap and water, or with an antimicrobial soap and water, to be more effective at removing C. difficile spores than alcohol-based hand hygiene products from the hands of volunteers inoculated with a known number of C. difficile spores (3;4). The primary reason hand hygiene with soap and water is not recommended for CDI prevention in non-outbreak settings is there are no studies that have found an increase in CDI with the use of alcohol-based hand hygiene products or a decrease in CDI with the use of soap and water (5-11). Conversely, several of the studies did identify decreases in methicillin-resistant Staphylococcus aureus (6-8;11) or vancomycin resistant enterococcus (7) associated with the use of alcohol-based hand hygiene products. The combination of these findings, lack of change in CDI but decreases in other non-spore forming, multidrug resistant pathogens, with the use of alcohol-based hand hygiene products are the basis behind not recommending preferential use of soap and water for CDI prevention in nonoutbreak settings. However because of the theoretical increase in risk of C. difficile transmission based on the volunteer hand contamination studies, the experts who wrote the CDI component of the SHEA / IDSA Compendium and the SHEA / IDSA Clinical Practice Guidelines for CDI felt it was prudent to recommend preferential use of soap and water after caring for a patient with CDI in outbreak settings.

C. diﬃcile and Hand Hygiene for Healthcare Se2ngs 51

Clean Hands Save Lives Clean hands are the most important factor in preven8ng the spread of disease and an8bio8c resistance in se2ngs across the con8nuum of health care. Hand hygiene: §  Promotes pa8ent/resident safety and prevents infec8ons §  Reduces the incidence of healthcare-‐associated infec8ons such as C. diﬃcile infec8on 52

Hand Hygiene for Clostridium diﬃcile •  Perform hand hygiene whenever hands are visibly soiled, dirty, or contaminated AND –  before pu2ng on gloves –  before contact with the pa8ent/resident –  aFer removing gloves –  aFer contact with the environment –  before leaving the pa8ent/ resident area –  aFer using the restroom

Hand Hygiene: Soap vs. Alcohol-‐based Products •  Because alcohol does not kill C. difficile spores, use of soap and water is theore8cally more effec8ve than alcohol-‐based hand rubs. •  However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inac8va8on of other common pathogens. •  Discouraging the use of alcohol-‐based hand rubs may undermine overall hand hygiene program with unintended consequences for HAIs in general hMp://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html hMp://www.shea-‐online.org/Portals/0/CDI%20hand%20hygiene%20Update.pdf 54

Hand Hygiene for Clostridium diﬃcile (conAnued) not use alcohol-‐based •  In outbreaks se2ngs, do

hand rubs when caring for the C. diff pa8ent/ resident – use soap and water •  Washing away the spores with soap and water may be the best way to perform hand hygiene when transmission of C. difficile is occurring •  Some facili8es may choose to use soap and water as the recommended form of hand hygiene all of the Ame when healthcare workers caring for confirmed or suspected C.diff pa8ents/residents

Monitoring Hand Hygiene Compliance Any possible beneﬁt from ins8tu8ng a “soap and water only” policy must be balanced against the poten8al for decreased compliance resul8ng from a more complex hand hygiene message. Monitoring compliance with appropriate hand hygiene prac8ces is important! 56

Monitoring Hand Hygiene Compliance: Methods The most commonly used method to track rates of hand hygiene compliance is called direct observaAon, (or the secret shopper), which involves someone watching and recording the hand hygiene behavior of health care workers

Hand Hygiene/IsolaAon ObservaAon Tool

In Conclusion •  On the surface, hand hygiene may seem like a basic prac8ce, yet it remains an integral important infec8on preven8on strategy in our toolbox and one of the most diﬃcult healthcare worker behaviors to change. •  Remember: staﬀ, pa8ent, and resident health is dependent upon hand hygiene compliance.

Check with the nursing staﬀ before entering this room

Gloves and gown required. Remove gown and gloves before leaving this room. Hand hygiene required. Preferred method of hand hygiene is to wash your hands for 15 seconds with soap and water. 60

þ

CONTACT PLUS PRECAUTIONS Private Room is Indicated

VISITORS report to the nursing station before entering the patient room. Perform hand hygiene with soap and water before leaving room. Clean Room with Bleach Lávese las manos con agua y jabón. La habitación debe ser limpiada con cloro o lejía EVERYONE (INCLUDING VISITORS) ENTERING THIS ROOM MUST:

Perform Hand Hygiene

Before and after patient care and/or contact with the environment

Wear Gloves

Upon entry into the room if direct contact with patient or environment is anticipated

Wear Gown

Upon entry into the room if direct contact with patient or environment is anticipated

Dedicate Patient Care Equipment

Limit the movement/transport of patient Place clean gown/sheet on patient if transport is necessary

Los visitantes deben presentarse primero al puesto de enfermeria al entrar. Lávese las manos con agua y jabón. Póngase guantes al entrar al cuarto.

CONTACT PLUS PRECAUTIONS In addition to Standard precautions, use Contact PLUS Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items and surfaces in the patient’s environment. Examples of such illnesses include: • • • •

Clostridium difficile (C-Diff) Diarrhea: acute diarrhea with a likely infectious cause or in an adult with a history of recent antibiotic use Norovirus / Rotavirus Enteric Infections including but not limited to: o Campylobacter o Cryptosporidium o Salmonella o Shigella o Escherichia coli 0157:H7 The above information is not an all inclusive list of illnesses/conditions that require transmission-based precautions. Please contact Infection Prevention for guidance with additional illnesses/conditions. THIS SIGN TO BE REMOVED BY ENVIRONMENTAL SERVICES ONLY.

Check with the nursing staﬀ before entering this room

þ

Gloves and gown required. Remove gown and gloves before leaving this room. Hand hygiene required. Preferred method of hand hygiene is to wash your hands for 15 seconds with soap and water. 63

HELP PREVENT THE SPREAD OF INFECTION BEFORE ENTERING THIS ROOM: Visitors: Please see staff to find out how you can help protect yourself and others. Staff: Every time, appropriately wash hands with soap and water, wear gown and gloves, use disposable single-use or patient/residentdedicated noncritical care equipment, and use appropriate disinfectant.

Special Contact Precautions Questions? Please call your local health department 64

SPECIAL CONTACT PRECAUTIONS: Apply to diseases* likely to have spores (i.e., Clostridium difficile) and some diseases* with ongoing transmission (i.e., norovirus). Wash hands with

Use adequate amount of friction for at least 15 seconds ***********************************************************************************************************

soap and water Gown & gloves

Before & after patient/resident contact After contact with objects/surfaces near patient/resident After removing gloves Upon room entry Discard before leaving room

Noncritical patient/resident care equipment

Always use disposable single-use or patient/resident-dedicated equipment

Hypochlorite solution (e.g., bleach)

Consider use of 10% hypochlorite solution during continued transmission and/or for all cases

*Consult the most up-to-date infection prevention guidance and/or your local health department with questions. 65

Environmental cleaning of Clostridium difficile

www.notjustamaidservice.com

Cleaning Pocket Card

DISINFECTION GUIDE FOR HIGH TOUCH POINT SURFACES Routine disinfecting of “high touch point” surfaces reduces growth and transmission of viruses and bacteria by eliminating growth reservoirs. Prior to disinfecting any surface, you must clean to remove any particulate or gross debris.

Identified High Touch Point Surfaces • Door knobs/handles • Door jams/surfaces • Bed rails/Headboards/Footboards • Bedside table • Bedside commode • Phone/call buttons • Light switches • Furniture/patient chair • Medical equipment • Countertops & other horizontal surfaces

ROOM CLEANING CHECKLIST Perform hand hygiene Don personal protective equipment (PPE) Remove dirty/used items Clean/disinfect high touch point surfaces Damp dust (do not dust over patient): • TV stand • Window sills • Lights & vents Clean/disinfect bathroom: • Door, door jam & door knob • Handrails • Mirror • Sink/faucet • Tub/shower • Toilet seat/usher Replace hand sanitizer/soap, paper towels & syringe boxes, as needed Replace trash liner, discard dust cloth, change mop head Remove PPE Perform hand hygiene This material was prepared by the Centers for Disease Control and Prevention (CDC). It is provided by VHQC, the Medicare Quality Improvement Organization for Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reect CMS policy. VHQC/IIPC/5/11/2012/1321

Environmental Cleaning

Background According to the Centers for Disease Control and Preven7on (CDC), cleaning and disinfec7ng environmental surfaces in healthcare facili7es is essen.al to reducing the poten7al contribu7on of those surfaces to the occurrence of healthcare–associated infec7ons (HAIs).1 •  Environmental surfaces can serve as reservoirs for certain microorganisms that cause infec7ons.2 •  Some pathogens, such as Clostridium difficile, can remain ac7ve on environmental surfaces for extended periods of 7me, poten7ally leading to the transmission of disease in the healthcare seGng. Every day, facili7es face mul7ple challenges to effec7vely and efficiently clean and disinfect their environment and medical devices.

1.  2.

Fuglsang M.: Tips for Cleaning and Disinfec6ng Environmental Surfaces. hMp://www.infec7oncontroltoday.com/ar7cles/4a1enviro.html (accessed January 4, 2013). ν HICPAC guidelines for environmental infec7on control in health-‐ care facili7es, 2003. MMWR: Centers for Disease Control and Preven7on: Morb Mortal Wkly Rep 52(RR-‐10), Jun. 6, 2003. hMp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm (accessed Jan.4, 2013).

Eﬀec.ve environmental cleaning and disinfec.on strategies may include: •  Educa7ng personnel on p roper cleaning and •  •  •  •  •

disinfec7ng techniques frequently due to high staﬀ turnover. Ensuring that educa7on is provided in a language and at a reading level that will be understood by employees Daily cleaning and disinfec7on of high-‐touch surfaces Monitoring for compliance with recommended prac7ces and providing feedback to environmental services Op7mizing cleaning products and technologies Addressing challenges and barriers as they arise

Something to remember… Transmission of infec7on may not be a failure of the cleaning and disinfec7ng agents but rather a failure to completely follow the cleaning and disinfec7ng process. Approach cleaning in a orderly, regularly scheduled method. •  Clockwise or counter-‐clockwise •  Working from top to boMom •  Cleanest to the dir7est 72

Common terms •  Clean = remove all visible dust, soil, and any other foreign material •  Decontaminate = remove disease-‐producing microbes to make safe for handling •  Disinfect = kill or destroy nearly all disease-‐ producing organisms (except spores) using a chemical or physical agent •  Sterilize = destroy microorganisms and spores Adapted from the APIC, 2009 Infec7on Preven7on Manual for Long-‐Term Care Facili7es 73

Cleaning: the ﬁrst step

•  Cleaning is the physical removal of all visible soil and other foreign material (such as dirt, dust bunnies, and body fluids) so you can get to the microbes underneath. You can’t kill microbes if you cannot get to them. •  One can clean without disinfec7ng, but one can not disinfect without cleaning, therefore, one must clean first to remove the materials. •  Cleaning agents such as detergents do not have an7microbial claims. •  Clean spills of blood and body fluids as soon as they occur.

Disinfectants •  Substances applied to inanimate objects to destroy microorganisms. •  Use products registered with the Environmental Protec7on Agency (EPA) for use in medical facili7es. •  Disinfectant will have claims that it can kill certain types of microorganisms – make sure you know what the product can and cannot kill. 75

Read the label •  Cleaners and disinfectants should be reviewed for use, dilu7on, contact 7me, and shelf life –  Contact .me: amount of 7me needed for the chemical to come in contact with the microorganism so that a signiﬁcant number of organisms are killed. –  Shelf life: how long the chemical can be used. Ager the shelf life expires, the product is no longer as eﬀec7ve at doing its job.

Remember that bleach solu7ons should be prepared fresh daily 76

Rou.ne cleaning/disinfec.on for standard room (no noted C. diﬀ)

•  Use EPA-‐registered disinfectant -‐ Quaternary ammonia-‐based disinfectants are widely used in healthcare seGngs.

•  Consider disinfectant wipes for use by healthcare workers

Cleaning and disinfec.ng the room of a pa.ent with C. diff Use for C. diff outbreak situa7ons, and possibly throughout units with high C. diff rates or with ongoing C. diff transmission •  Clean first • Units with high C. diff rates should consider using a disinfectant such as hypochlorite bleach solu7on (1:10 dilu7on if using 5.25% sodium hypochlorite) or an EPA-‐registered disinfectant with a sporicidal claim

Why not always use bleach-‐based products? •  Bleach-‐based products can cause corrosion/ piGng of some equipment and surfaces over 7me. •  May cause respiratory irrita7on. •  Requires careful dilu7on (e.g., solu7on for food surfaces VERY diﬀerent than general environmental cleaning). •  Bleach is a corrosive chemical and must be used with cau6on. AHer a 10 minute contact 6me, rinse with water.

Challenges •  •  •  •

Administra7ve Technical Physical Educa7onal

Staﬀ turnover: the revolving door

Confusion about who cleans what and when

Confusion about products

Cleaning can be diﬃcult

Technical issues •  Suﬃcient contact 7me to kill pathogens •  Pre-‐cleaning to remove organic material •  Mechanical removal

When and how should portable equipment be cleaned? SHEA/IDSA Guideline for preven7on of CDI •  Use dedicated pa7ent care items and equipment; if items must be shared, clean and disinfect the equipment between pa7ents •  Develop and implement protocols for disinfec7on of equipment and the environment

Environmental transmission •  Frequency of C. difficile acquisi7on has been linked with the level of environmental contamina7on •  Pa7ents admiMed to a room previously occupied by a pa7ent with C. difficile have a higher risk for C. difficile acquisi7on •  Improved room disinfec7on has led to decreased rates of C. difficile infec7on

Germicidal wipes •  If wipes are used: –  The wipe must wet the surface being disinfected –  Use the right wipes for the right type of job –  The user should: •  Know the contact 7me for the germicide used •  Know the ability of the wipe to maintain contact 7me for the task for it will be used •  Be involved in selec7on of the right type of wipes

–  Staﬀ must be trained to use the wipes appropriately (for example, wear gloves when using cleaning products)

Monitoring environmental cleaning •  Consistency with recommended cleaning and disinfec7on procedures should be rou7nely monitored. –  Include all surfaces and items near the pa7ent

•  Staﬀ performing cleaning should use checklists

–  Conﬁrm that each cri7cal area has been cleaned and disinfected –  Each item must be checked oﬀ as it is completed

•  If there is ongoing transmission:

–  May indicate non-‐compliance –  Thorough cleaning and disinfec7on of the environment must be done –  Increase frequency of monitoring compliance with cleaning and disinfec7on procedures

Environmental services staﬀ •  Engage environmental services, especially front line personnel –  Make them a part of the team! –  Involve in decision-‐making process (such as product selec7on) when possible

•  Instruct using basic infec7on preven7on methods •  Train with ac7vi7es that relate directly –  Hands-‐on demonstra7ons –  Address any language or cultural barriers –  Appropriate educa7onal level

•  Encourage open communica7on and share appropriate feedback in a non-‐puni7ve manner 91

Environmental services training Produced by the Illinois Department of Public Health •  www.notjustamaidservice.com/ •  www.youtube.com/notjustamaidservice

Conclusion Cleaning well enough to pass the white glove test is not good enough to ensure that an environment is free from microbial contamina7on.

Think before you clean!

Implementing an Antimicrobial Stewardship Program

Antibiotic Stewardship ResourcesVHQC/VDH C. difficile Infection Prevention Collaborative General Resources, Guidelines, and Policy Statements • CDC Get Smart for Healthcare website: www.cdc.gov/getsmart/healthcare • CDC Antibiotic Resistance website: www.cdc.gov/drugresistance/index.html • Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) • Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship (2007): www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Antimicrobial%20Stewardship.pdf • Policy Statement on Antimicrobial Stewardship by SHEA, IDSA (2012): www.shea-online.org/View/smid/428/ArticleID/141.aspx

Resource Guides, Toolkits, and Change Packages • Greater New York Hospital Association Antimicrobial Stewardship Toolkit: http://gnyha.org/11513/File.aspx o Evaluation and Research on Antimicrobial Stewardship’s Effect on C. difficile Project Toolkit (companion to GNYHA toolkit): www.ahrq.gov/qual/cdifftoolkit/cdiffl2qu.htm (Questions to Consider) www.ahrq.gov/qual/cdifftoolkit/cdiffl2tools.htm (Summary of Tools and Resources) • Institute for Healthcare Improvement (IHI) and CDC Antibiotic Stewardship Drivers and Change Package: www.cdc.gov/getsmart/healthcare/learn-from-others/driver-diagram/index.html • Minnesota Guide to a Comprehensive Antibiotic Stewardship Program: www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/index.html

Long-Term Care • Antibiotic Use in Nursing Homes fact sheet – from CDC Get Smart Week (2012): www.cdc.gov/getsmart/healthcare/learn-from-others/factsheets/pdf/getsmart-LTC_nursinghomes_9_17_12.pdf • Antimicrobial Stewardship in Long-Term Care - Medscape commentary (2012): www.medscape.com/viewarticle/762755_1 • Antibiotic Stewardship Programs in Long-Term Care Facilities – Annals of Long-Term Care: Clinical Care and • Aging 2011;19:20-25. www.annalsoflongtermcare.com/article/antibiotic-stewardship-programs-long-term-care-facilities

CME/CE Opportunities • Antimicrobial Stewardship: Practical Strategies for the Healthcare Team: www.medscape.org/viewprogram/32553 o Includes modules on stewardship in environments with limited resources, partnering with the microbiology lab, and more • Antimicrobial Stewardship for the Community Hospital: Practical Tools and Techniques for Implementation: www.cdc.gov/getsmart/healthcare/learn-from-others/CME/antimicrobial-resistance.html#Stewardship • Antimicrobial Resistance Across the Continuum of Care: Winning the War One Battle at a Time: www.cdc.gov/getsmart/healthcare/learn-from-others/CME/antimicrobial-resistance.html#Antimicrobial

Clostridium difficile Infection (CDI) or Clostridium difficile Associated Diarrhea (CDAD) or just plain

C diff

Disclosure of faculty financial affiliations Jointly sponsored by the University of Virginia School of Medicine and Virginia Health Quality Center. Joint sponsorship statement-This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of University of Virginia School of Medicine and Virginia Health Quality Center (VHQC). The University of Virginia School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Credit designation statement The University of Virginia School of Medicine designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits.TM Physicians should claim only the credit commensurate with the extent of their participation in the activity. The speaker, Molly Oâ&#x20AC;&#x2122;Dell, MD, does not have any financial conflicts or affiliations to disclose. There is no commercial support for this activity.

Completing this online activity consists of five steps: 1) Watch the lecture/video 2) Take the post test and get 80% of the questions correct 3) Complete the evaluation form 4) Fill out and print your certificate of hours completed Release Date: April 2013 Valid for credit through: April 2014

Objectives 1. Describe the pathophysiology of Clostridium difficile (CDI) 2. Analyze the burden of Clostridium difficile 3. Describe the changing epidemiology of Clostridium difficile 4. Identify important risk factors for initial CDI and recurrence 5. Discuss treatment of Clostridium difficile 6. Discuss evidence-based prevention strategies

Why Be Concerned? Clostridium difficile (C. diff) infection (CDI) is a troublesome, opportunistic pathogen that causes significant burden to the patient and the healthcare system.

100

C. difficile Pathophysiology â&#x20AC;˘ Anaerobic spore-forming bacillus â&#x20AC;˘ Fecal-oral transmission through contaminated environment and hands of healthcare personnel CDI is a bacterial pathogen that causes disease with a wide spectrum of severity, ranging from mild diarrhea to pseudomembranous colitis and death.

Healthy colon

Pseudomembranous colitis 101

Pathogenesis of C. diff-associated Diarrhea (CDAD; CDI) Antibiotic therapy

Disturbed colonic microflora C. diff exposure and colonization Toxin A and Toxin B

Diarrhea and colitis 102

Pathogenesis cont.

103

Changing Epidemiology Although CDI has been a well-described condition since its discovery in 1978, changes in the epidemiology of this disease have been observed during the past several years.

104

CDI Epidemiology • Severity of CDI appears to be increasing • Increased morbidity and mortality • Severe infections in low-risk populations • Emergence of novel, hypervirulent strain (BI/NAP1/027) now reported across the U.S., Canada and Europe • Resistance to fluoroquinolones • Increased toxin production and sporulation may contribute to severe and widespread disease • Leading cause of healthcare-associated infectious diarrhea in the U.S. Gould, C. (2008), Changing Epidemiology and Prevention of Clostridium difficile Infection. Centers for Disease Control and Prevention. Retrieved from http://emergency.cdc.gov/coca/summaries/pdf/Cdiff-091608_Draft.pdf

105

Clostridium difficile Associated Diarrhea (CDAD) • • • •

Most common nosocomial diarrhea Associated with antibiotic usage Conditions with decreased gastric acidity Infection can range from asymptomatic to death from toxic megacolon C. difficile spores lie dormant inside the colon until a person takes an antibiotic. The antibiotic disrupts normal gut flora preventing C. difficile from transforming into its active, disease causing bacterial form. As a result, C. difficile transforms into its infectious form and then produces toxins.

106

Cases of HFOHFA C difficile at CRMH October 2010 through April 2011 = 50 HFOHFA = Health facility or Health facility associated

A Matched Case Control Study Was Undertaken

107

Results of McNemar's test for a case-control study Antibiotics Summary: If there were no association between the risk factor and the disease, you'd expect the number of pairs where cases was exposed to the risk factor but control was not to equal the number of pairs where the control was exposed to the risk factor but the case did not. In this study, there were 11 discordant pairs (case and control had different exposure to the risk factor). There were 1 ( 9.091%) pairs where the control was exposed to the risk factor but the case was not, and 10 ( 90.909%) pairs where the case was exposed to the risk factor but the control was not. P Value: The two-tailed P value equals 0.0159 By conventional criteria, this difference is considered to be statistically significant. The P value was calculated with McNemar's test with the continuity correction. Chi squared equals 5.818 with 1 degrees of freedom.

Cases were 10X more likely To have been exposed to antibiotics and to achieve significance

Odds ratio: The odds ratio is 10.000, with a 95% confidence interval extending from 1.423 to 433.977

Control + Case

108

- Total

Total

PPIs: McNemarâ&#x20AC;&#x2122;s method Summary: If there were no association between the risk factor and the disease, you'd expect the number of pairs where cases was exposed to the risk factor but control was not to equal the number of pairs where the control was exposed to the risk factor but the case did not. In this study, there were 15 discordant pairs (case and control had different exposure to the risk factor). There were 3 ( 20.000%) pairs where the control was exposed to the risk factor but the case was not, and 12 ( 80.000%) pairs where the case was exposed to the risk factor but the control was not. P Value: The two-tailed P value equals 0.0389 By conventional criteria, this difference is considered to be statistically significant. The P value was calculated with McNemar's test with the continuity correction. Chi squared equals 4.267 with 1 degrees of freedom.

Cases were 4X more likely To have been exposed to PPIs and to achieve significance

Odds ratio: The odds ratio is 4.000, with a 95% confidence interval extending from 1.079 to 22.088

Control Case

Total

50 109

For 29 Months (FY09-FY10 & 5 Months of FY11) the Average of the Daily Drug Dose For Each Antibiotic for Each Month was Compared to the Rate of C diff for Each Month DDD/Ampicillin / sul DDD/Azithromycin DDD/Cefazolin DDD/Cefepime DDD/Ceftriaxone 0.08390086 0.108179845 0.048015957 0.203715347 0.001411759

Correlation Coeficient = r r2 = Sample Size = 29 Probability two tailed Probability one tailed

0.007039354

0.011702879

0.002305532

0.041499943

0.994249

0.665229

0.576729

0.804707

0.289204

0.497125

0.332614

0.288364

0.402353

0.144602

DDD/Ciprofloxacin -0.053906704

Correlation Coeficient = r r2 =

Correlation Coeficient = r

DDD/Clindamycin DDD/Daptomycin DDD/Ertapenem DDD/Erythromycin 0.404437748 0.006038782 0.13172045 -0.032511939

0.002905933

0.163569892

3.65E-05

0.017350277

0.001057026

0.781247

0.029741

0.975357

0.495868

0.867084

0.390623

0.014871

0.487679

0.247934

0.433542

Sample Size = 29 Probability two tailed Probability one tailed

DDD/Rifampin -0.067553026

DDD/Sulfa / Trim 0.023909659

DDD/Vancomycin 0.498962413

0.004563411

0.000571672

0.248963489

0.72791 0.363955

0.902059 0.451029

0.005871 0.002935

r2 = Sample Size = 29 Probability two tailed Probability one tailed

Pearsonâ&#x20AC;&#x2122;s Correlation Coefficient Text in RED is significant 110

1.99306E-06

C diff Rate 1 1

Frequency of C. diff • 3 - 5% of adults are C. diff carriers • 50% of neonates are asymptomatic carriers • 25-30% of hospitalized adults are carriers

111

CDI Burden The dual increase in CDI incidence and severity has resulted in: • Rising inpatient costs • Readmission rates • Mortality rates

112

Burden of C. diff in Virginia • Hospitalizations for CDI more than tripled from 2000 to 2010 • The average cost for patients with CDI was $23,190 compared to $8,860 for patients hospitalized without CDI • Additionally, length of stay for patients diagnosed with CDI was three times as long compared to hospitalized patients without CDI in 2009 Virginia Health Information; dodging a “One-Two Punch” available at: www.vhi.org

113

Burden of C. diff â&#x20AC;˘ Nationally, from 2000 to 2009, the number of hospitalized patients with any CDI discharge diagnosis more than doubled â&#x20AC;˘ During the same timeframe, the number of hospitalized patients with a primary CDI diagnosis more than tripled â&#x20AC;˘ From 2000 to 2010, hospitalizations for C. diff more than tripled CDC. Vital signs: Preventing Clostridium difficile infections. March 2012. MMWR 2012; 61(09);157-162 114

Virulence • Approximately 3 million Americans are affected by CDI every year • According to the CDC, CDI contributes to 15,000-30,000 deaths annually • CDI is deadly – up to 1 in 40 elderly are affected 115

Death Rate Due to C. diff

116

Risk Factors for Initial CDI Classic risk factors: • • • •

Antibiotic therapy Advanced age Prolonged stay in healthcare facility High severity of illness

Additional risk factors: • • • •

Inflammatory bowel disease Gastrointestinal surgery Gastric acid suppression Immunosuppression 117

Multiple Episodes Recurrent CDI Rates of recurrent CDI: • 20% after first episode • 45% after first recurrence • 65% after two or more recurrence

118

Diagnosis The diagnosis of CDI should be based on a combination of clinical and laboratory findings. A case definition for the usual presentation of CDI includes: o The presence of diarrhea (defined as 3 or more unformed stools within 24 hours o Stool sample positive for C. diff (either by an assay for Toxins A and/or B, by culture, or by other means) and/or o Evidence of pseudomembranous colitis detected during endoscopy or surgery or on histopathologic examination

Cohen SH, et al Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA);2010:21;431-455 119

Actions of Toxin A and Toxin B

C. difficile produces toxin A and toxin B (TcdA and TcdB). TcdA binds to the apical side of the cell and, after internalization, causes cytoskeletal modification and disruption of tight junctions. The resulting loss of epithelial barrier function facilitates TcdA and TcdB to cross the epithelium with preferential binding of TcdB to the basolateral cell membrane. Both toxins are cytotoxic and lead to production of proinflammatory cytokines, increase in vascular permeability, recruitment of neutrophils and monocytes, epithelial cell apoptosis and connective tissue degradation, resulting in pseudomembrane formation and diarrhea. Further, the activation and release of various neuropeptides by the toxins stimulates ENS to elicit fluid secretion, causing diarrhea. 120

Besides the direct effects of the toxins, other mechanisms underlying C. difficile associated diarrhea include inflammation and activation of neuropeptides. The C. difficile toxins initiate an extensive inflammatory cascade that causes increased damage to host tissues resulting in fluid exudation. TcdA causes release of several proinflammatory cytokines such as leukotriene, PGE2, and tumor necrosis factor (TNFÎą in vivo). It also directly activates monocytes to release IL-1 and IL-6, and increase neutrophil migration in vitro. Other toxin-mediated inflammatory effects include release of reactive oxygen species, activation of mitogen activated protein kinases. 121

Pseudomembranous Colitis

122

Clinical Features Mild C. difficile colitis: • low-grade fever • diarrhea (5-10 watery stools a day) • mild abdominal cramps and tenderness. Severe C. difficile colitis: • high fever (102°F to 104°F) • > 10 watery stools a day with blood • severe abdominal pain and tenderness. Others: • Dehydration • Electrolyte disturbances • Peritonitis • Megacolon • Perforation

123

Management of C difficile Colitis 1. Correction of dehydration and electrolyte deficiencies 2. Discontinuing the antibiotic that caused the colitis, and 3. Using antibiotics to eradicate the C. difficile bacterium. In patients with mild colitis, stopping the antibiotic that caused the infection may be enough to cause the colitis and diarrhea to subside. In most cases, however, antibiotics are needed to eradicate the C. difficile bacteria.

124

Antibiotic Treatment of C difficile Colitis â&#x20AC;˘ Antibiotics - oral or IV metronidazole: 250-500 mg orally 4 times daily or 500750 mg orally 3 times daily for 10 days - oral vancomycin (capsules, oral solution): Adults and teenagersâ&#x20AC;&#x201D;125 to 500 mg every six hours 10 days. Children 10 mg per kilogram of body weight, up to 125 mg every six hours for 10 days. - rectal vancomycin 500 mg in 250 mL NS every 6 hours as a retention enema(clamp rectal tube x 1 hour with each dose) - oral fidaxomicin: 200 mg orally twice daily for 10 days ($3,000)

20% rate of relapse 125

Treatment options for relapses of C. difficile colitis 1. A second course of the same or a different antibiotic 2. Six weeks of treatment with decreasing doses of antibiotics 3. An oral resin by mouth such as cholestyramine that binds toxins and inactivates them 4. Non-pathogen yeast by mouth such as Saccharomyces boulardii, for example, Florastor Others - IVIG - fecal transplant 126

Core Prevention Strategies • Educate about CDI: healthcare workers, housekeeping, administration, patients/residents, families • Measure compliance with hand hygiene and contact precaution recommendations – Soap and water preferred over alcohol-based hand rub in outbreak setting

127

Core Prevention Strategies • Contact precautions for duration of diarrhea – Use of gloves only A1 recommendation

• Cleaning and disinfection of equipment and environment • Laboratory-based alert system for immediate notification of positive test results Strategies to Prevent C. difficile Infections in Acute Care Hospitals Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92. 128

Post Test, Evaluation, & Certificate In order to obtain your certificate you must complete the post test and evaluation. Please click on the link below: http://cmetracker.net/UVACME/Login?FormNa me=RegLoginLive&eventid=19826

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Clostridium diﬃcile Educa'on Guide

130

What is Clostridium difficile? •  Clostridium difficile, also known as C. difficile or C. diff, is a gram-‐posi/ve, anaerobic, spore-‐forming bacterium that can cause a serious intes/nal infec/on in vulnerable pa/ents or residents. •  C. diff bacteria are found in the feces and are spread by direct or indirect contact.

•  C. diﬀ is most likely to aﬀect pa/ents taking an/bio/cs in hospitals or long-‐term care facili/es, but can occasionally cause problems in healthy people.

131

What Causes C. diff Infec'on? •  Certain circumstances such as the use of an/bio/cs, especially broad-‐spectrum an/bio/cs (those that are able to kill a wide variety of bacteria) disturb the balance of “good” bacteria and that normally keep other bacteria like C. diff in check in the intes/nal tract. This change of balance allows C. diff bacteria to mul/ply. •  When C. diff bacteria mul/ply, they can produce toxins that aCack the lining of the intes/nes, which can lead to illness ranging from mild diarrhea to severe inflamma/on of the colon.

132

What Are the C. diff Infec'on Trends? •  The incidence, mortality, and medical costs of Clostridium difficile infec/on (CDI) has reached historically high rates, impac/ng the en/re healthcare spectrum. •  According to the Centers for Disease Control and Preven/on (CDC), from 2000 to 2009, na'onally, the number of hospitalized pa/ents with any C. diff discharge diagnosis more than doubled. –  During the same /me period, in Virginia, this trend has con/nued: the annual rate of hospitaliza/on for C. diff has more than tripled.

133

Two Major Reservoirs for C. diﬀ in the Healthcare Environment •  Pa/ents/residents with symptoma/c infec/on (CDI) or asymptoma/c carriage (also known as “coloniza/on”) in the feces –  Can be spread to other pa/ents/residents via the contaminated hands of healthcare workers

•  Inanimate objects in the environment such as hard surfaces, medical equipment, and pa/ent/resident items

134

C. diff Transmission Within the Healthcare SeDng: Direct Contact •  Direct contact: Healthcare workers can spread C. diff bacteria from an affected pa/ent/resident to a suscep/ble one if their hands are contaminated (thought to be most likely mode of transmission)

o  Examples of ac/vi/es that may result in transfer of C. diﬀ organisms: toile/ng, feeding or medica/on administra/on, oral care, or suc/oning o  Remember that family members and visitors can get contaminated hands too! 135

C. diﬀ Transmission Within the Healthcare SeDng: Indirect Contact •  Indirect contact: C. diﬀ bacteria can be transmiCed from contaminated environmental surfaces such as high-‐ touch areas in pa/ent/resident rooms, medical equipment, and pa/ent/ resident items

o  Touching items or surfaces that are contaminated with feces containing C. diff and then touching the mouth or mucous membranes can transmit C. diff. o  C. diff bacteria in vegeta/ve state do not last long in the environment but spores can persist for months.

136

How C. diﬃcile May Spread Between Healthcare Facili'es

137

Who is at Risk for Developing C. diﬀ Infec'on (CDI)?

138

Risk factors: •  Exposure to an/bio/cs, especially broad spectrum an/bio/cs •  History of long stays in healthcare seUngs (e.g., hospitals, nursing homes) •  Advanced age (over 65 years old) •  Serious underlying illnesses or condi/ons (such as cancer, liver disease, or kidney disease) •  Weakened immune system •  Gastrointes/nal problems or prior stomach/bowel surgery •  History of proton pump inhibitor (PPI) use •  Prior C. diﬀ infec/on

What Are the Signs and Symptoms for Mild to Moderate C. diﬀ Infec'on? •  Watery diarrhea (i.e., three or more /mes a day above what is normal for that person) •  Mild abdominal cramping, pain, and tenderness •  Fever •  Loss of appe/te •  Nausea

139

What Other Condi'ons Might Result From C. diﬀ Infec'on? •  Pseudomembranous coli/s

o  Inﬂammatory condi/on of the colon resul/ng from toxin produc/on

•  Toxic megacolon

o  Pa/ents o^en present with peritoneal signs such as abdominal disten/on, fever, hypotension, and leukocytosis

•  Colon perfora/on •  Sepsis •  In some rare incidences… death 140

What Are Some of the Signs and Symptoms of Severe C. diﬀ Infec'on? •  Inﬂamed colon (coli/s)

•  Patches of aﬀected /ssue in the colon that can bleed or produce pus (pseudomembranous coli/s) •  Extreme watery diarrhea such as 10 or more /mes a day •  Severe abdominal cramping •  Fever •  Blood or pus in the stool •  Dehydra/on •  Loss of appe/te •  Weight loss 141

What is the Difference Between C. diff Infec'on and C. diff Coloniza'on? C. diff infec'on •  Person displays ac've signs and symptoms of C. diff (e.g., has diarrhea, fever, etc.) •  Lab tests posi/ve for C. diff organism and/or C. diff toxin •  C. diff may be easily transmiCed 142

C. diff coloniza'on •  Person displays no clinical symptoms of C. diff (e.g., has formed stool, no fever, etc.) •  Lab tests posi/ve for C. diff organism and/or C. diff toxin •  C. diff may be transmiCed, but not as easily

Treatment •  Varies based on severity of symptoms and individual pa/ent factors (including history of prior C. diﬀ infec/on), but may include: –  Discon/ning the an/bio/c(s) that poten/ally caused the infec/on. •  In some cases of mild to moderate C. diﬀ infec/on (~20%), this may be enough to stop the infec/on.

–  Targeted an/bio/c therapy (usually vancomycin or metronidazole) –  Surgery (for severe cases)

•  20-‐30% of pa/ents treated for a C. diﬀ infec/on will have a repeat infec/on or relapse of their symptoms •  If treatment is successful and symptoms resolve, repeat tes/ng is not recommended. 143

Preven'on Strategies •  Iden/fy and isolate suspected cases quickly •  Use your facility’s Enhanced Contact Precau/ons for pa/ents/residents with known or suspected C. diﬀ infec/ons

144

–  Place person in private room or cohort with other persons with C. diff infec/on or coloniza/on –  Use personal protec/ve equipment: gowns and gloves per your facility’s policy –  Prac/ce enhanced hand hygiene (some facili/es recommend hand washing with soap and water aêr contact with a person with C. diff since alcohol does not kill C. diff spores). –  Dedicate medical equipment

Preven'on Strategies (cont’d) •  U/lize an environmental cleaning and disinfec/on protocol that includes:

–  Implemen/ng adequate cleaning and disinfec/ng for environmental surfaces and reusable devices –  Ensuring high touch surfaces are cleaned and disinfected, especially items likely to be contaminated with feces –  Using Environmental Protec/on Agency (EPA) registered products with sporicidal claims and/or hypochlorite-‐based products for cleaning and disinfec/ng for preven/ng the spread of C. diﬀ –  Following manufacturer’s guidelines for disinfec/on and cleaning of medical devices

145

Preven'on Strategies (cont’d) •  Implement an/bio/c stewardship program ini/a/ves to reduce: –  Inappropriate use of an/microbials –  Redundant and unnecessary broad spectrum an/microbials –  Dura/on of therapy

•  Pa/ent/resident, family, and staﬀ educa/on

146

Preven'on Strategies (cont’d) •  Conduct surveillance for C. diﬀ infec/on and monitoring compliance with hand hygiene, contact precau/ons, and environmental cleaning •  Provide pa/ents and residents opportuni/es for hand hygiene before ea/ng, a^er toile/ng, and when entering and leaving their room environment 147

Communica'on •  Inform and instruct all members of the care team in transmission-‐based precau/ons, enhanced hand hygiene prac/ces, and any special disinfec/on prac/ces and products •  Transfer informa/on backwards and forwards within the facility and between facili/es to provide for proper room selec/on, and ins/tu/on of precau/ons to prevent transmission of C. diﬀ 148

Post Test 1.  ___ True or ___False

1.  Strategies to prevent C. diff include: Droplet precau/ons, appropriate use of an/bio/cs, and rapid iden/fica/on of suspected/confirmed cases.

2. ___ True or ___False

2.  It is recommended that healthcare facili/es use dedicated medical equipment for pa/ents/residents with C. diﬀ infec/on

3. ___ True or ___False

3.  Mild to moderate signs and symptoms of C. diﬀ include: abdominal pain, nausea, and diarrhea 149

Post Test 4. __ True or 4. Aêr treatment, it is recommended to retest for ___False presence of C. diff 5. C. diff infec/ons can some/mes 5. ___ True or resolve without addi/onal ___ False medicine or special treatment 6. C. diff is caused by a virus that 6. ___ True or lives in the bowel ____ False 150

Post Test 7. __ True or __ False

7. A person can be colonized with C. diﬀ

8. __ True or __ False

8. In healthcare facili/es, C. difficile is most oên transmiCed to the pa/ent/resident via the contaminated hands of healthcare workers 9. C. diff spores are able to survive for a long /me outside of the body unless they are destroyed through a very thorough cleaning/disinfec/ng process

9. __ True or ___ False

151

Post Test 10. ___ True or ___ False

152

10. The popula/ons at greatest risk for acquiring C. diﬀ infec/on include: the elderly, people with a weakened immune system, and people who have stayed for an extended /me in a healthcare seUng (e.g., hospital or nursing home)

References •  APIC Implementa/on Guide: Guide to Preven/ng C. diﬃcile Infec/ons. February 2013. hCp://apic.org/Resource_/Elimina/onGuideForm/ 59397fc6-‐3f90-‐43d1-‐9325-‐e8be75d86888/File/2013CDiﬀFinal.pdf

•  CDC C. diﬃcile website:

hCp://www.cdc.gov/HAI/organisms/cdiﬀ/Cdiﬀ_infect.html

•  CDC Vital Signs: Making Health Care Safer: Stopping C. difficile Infec/ons. March 2012. hCp://www.cdc.gov/VitalSigns/Hai/StoppingCdifficile/ •  VDH C. difficile website: hCp://www.vdh.virginia.gov/epidemiology/surveillance/hai/cdiff.htm

•  VHQC C. diﬃcile collabora/ve resources: hCp://www.vhqc.org/qio/resources 153

What causes C. diff infection?

Things to remember about living with C. diff after returning home:

Antibiotic use is one of the most common causes of C. diff. This is why it is important to take antibiotics exactly as prescribed by your doctor.

Wash your hands often with soap and water, especially before preparing food or eating, as well as after using the bathroom.

Generally, when a person takes antibiotics, bacteria (both the good ones and the ones that cause disease) are destroyed. Sometimes the good bacteria are killed for several months. During this time, patients and residents can get sick from C. diff bacteria that are picked up from contaminated surfaces or items or from the hands of another person (such as a visitor or healthcare worker) who has touched a contaminated item or surface and has not cleaned his or her hands.

Who is at risk for getting an infection caused by C. diff? There is a greater chance for getting a C. diff infection if you are elderly or have certain medical problems that may weaken your immune system. Some of the factors that can increase the risk of getting a C. diff infection are: • Exposure to antibiotics • Use of proton pump inhibitors (i.e., medicines such as Nexium or Prilosec that work to decrease gastric acid production) • Recent gastrointestional (bowel) surgery or history of gastrointestinal problems • Lengthy stays in healthcare settings • Presence of a serious illness such as cancer, liver disease, or kidney disease • Advanced age

154

Family members or caregivers should wear gloves if their hands may come into contact with your stool, urine, or other body fluids, and they should wash their hands with soap and water before putting the gloves on and after removing them. Using a cleaner that contains bleach, frequently clean areas of the home that may become contaminated with C. diff, especially the bathrooms and areas that are touched frequently such as door knobs and light switches. Personal clothing, linens, and towels can be washed in the usual manner and do not require special handling. Inform all your healthcare providers that you have a history of C. diff infection so that they may take the appropriate precautions when caring for you. Talk to your doctor if you have any questions.

For more information:

Making a Difference in Virginia:

Clostridium difficile

Centers for Disease Control and Prevention

(C. diff) information

Virginia Department of Health

for patients, residents,

www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html www.vdh.virginia.gov/epidemiology/surveillance/ hai/cdiff.htm This material was prepared by VHQC, the Medicare Quality Improvement Organization for Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. VHQC/IIPC/5/29/2013/1610

and family members

What is Clostridium difficile (C. diff)?

How do I know if I have a C. diff infection?

Are there special precautions that will be in place during my healthcare stay?

Clostridium difficile (pronounced Klo-STRIDee-um dif-uh-SEEL) is also known as C. diff or C. difficile and causes Clostridium difficileassociated disease (CDAD) or Clostridium difficile infection (CDI).

Your doctor may think you have a C. diff infection if you have some of these symptoms:

If you are diagnosed with a C. diff infection, your healthcare workers will wear gloves and gowns when touching you or taking care of you to prevent spreading the C. diff germs to others.

These are all terms your healthcare providers may use to describe a condition caused by bacteria (germs) found in the intestines (bowels) and stool (bowel movement) of some people and animals. C. diff is the most common cause of infectious diarrhea in hospitals and longterm care facilities (nursing homes). Many different kinds of bacteria live in and on your body. Some bacteria play an important part in protecting your health, while others, such as C. diff, may cause illness. The most common symptoms of C. diff infection are: • Watery diarrhea (mild to severe) • Stomach pain and tenderness • Fever In severe cases, C. diff may cause parts of the bowel to die or not work correctly, and surgery may be needed to remove those parts. In rare cases, C. diff may lead to death.

155

• • • • •

Watery diarrhea Fever Loss of appetite Nausea Stomach pain/tenderness

Diarrhea can be caused by many reasons and not all diarrhea is due to C. diff. Therefore, if your healthcare provider thinks you may have C. diff, he or she may collect a stool sample and have it tested by the laboratory to see if C. diff is present.

If I have a C. diff infection, how will it be treated? Your healthcare provider will make the right treatment decision for you based on your symptoms and your medical history. If you are currently on an antibiotic, a mild C. diff infection often can be controlled simply by stopping the antibiotic. Sometimes, your doctor will give you a stronger antibiotic that is effective at treating C. diff. In severe cases, surgery may be needed to help you get better. After treatment, some people remain “colonized” with C. diff. This means that the bacteria remain in the body but do not cause any symptoms. Contact your doctor if your diarrhea does not go away or comes back, or if you develop new symptoms like fever or stomach pain/tenderness.

Your family members and friends who visit may also be asked to wear gowns and gloves when they enter your room. If your visitors have to use the restroom, they should not use the one in your room. It is also important that your healthcare providers and visitors wash their hands with soap and water before entering and after exiting your room. Feel free to remind everyone to wash their hands. You should keep your hands clean, too. Make sure to wash them after using the restroom, before eating or preparing food, and any time they are visibly dirty. You may also be asked to stay in your room or avoid going to “common” areas of the facility such as the cafeteria.

Making a Difference in Virginia: Clostridium difficile (C. diff) information for patients, residents, and family members What is Clostridium difficile (C. diff)? Clostridium difficile (pronounced Klo-STRID-ee-um dif-uh-SEEL) is also known as C. diff or C. difficile and causes Clostridium difficile-associated disease (CDAD) or Clostridium difficile infection (CDI). These are all terms your healthcare providers may use to describe a condition caused by bacteria (germs) found in the intestines (bowels) and stool (bowel movement) of some people and animals. C. diff is the most common cause of infectious diarrhea in hospitals and long-term care facilities (nursing homes). Many different kinds of bacteria live in and on your body. Some bacteria play an important part in protecting your health, while others, such as C. diff, may cause illness. The most common symptoms of C. diff infection are: • Watery diarrhea (mild to severe) • Stomach pain and tenderness • Fever In severe cases, C. diff may cause parts of the bowel to die or not work correctly, and surgery may be needed to remove those parts. In rare cases, C. diff may lead to death.

What causes C. diff infection? Antibiotic use is one of the most common causes of C. diff. This is why it is important to take antibiotics exactly as prescribed by your doctor. Generally, when a person takes antibiotics, bacteria (both the good ones and the ones that cause disease) are destroyed. Sometimes the good bacteria are killed for several months. During this time, patients and residents can get sick from C. diff bacteria that are picked up from contaminated surfaces or items or from the hands of another person (such as a visitor or healthcare worker) who has touched a contaminated item or surface and has not cleaned his or her hands.

For more information: Centers for Disease Control and Prevention www.cdc.gov/HAI/organisms/cdiff/ Cdiff_infect.html Virginia Department of Health www.vdh.virginia.gov/epidemiology/surveillance/hai/cdiff.htm

156

How do I know if I have a C. diff infection? Your doctor may think you have a C. diff infection if you have some of these symptoms: • • • • •

Watery diarrhea Fever Loss of appetite Nausea Stomach pain/tenderness

Are there special precautions that will be in place during my healthcare stay? If you are diagnosed with a C. diff infection, your healthcare workers will wear gloves and gowns when touching you or taking care of you to prevent spreading the C. diff germs to others. Your family members and friends who visit may also be asked to wear gowns and gloves when they enter your room. If your visitors have to use the restroom, they should not use the one in your room. It is also important that your healthcare providers and visitors wash their hands with soap and water before entering and after exiting your room. Feel free to remind everyone to wash their hands. You should keep your hands clean, too. Make sure to wash them after using the restroom, before eating or preparing food, and any time they are visibly dirty. You may also be asked to stay in your room or avoid going to “common” areas of the facility such as the cafeteria.

Things to remember about living with C. diff after returning home: Wash your hands often with soap and water, especially before preparing food or eating, as well as after using the bathroom. Family members or caregivers should wear gloves if their hands may come into contact with your stool, urine, or other body fluids, and they should wash their hands with soap and water before putting the gloves on and after removing them. Using a cleaner that contains bleach, frequently clean areas of the home that may become contaminated with C. diff, especially the bathrooms and areas that are touched frequently such as door knobs and light switches. Personal clothing, linens, and towels can be washed in the usual manner and do not require special handling. Inform all your healthcare providers that you have a history of C. diff infection so that they may take the appropriate precautions when caring for you. Talk to your doctor if you have any questions. This material was prepared by VHQC, the Medicare Quality Improvement Organization for Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. VHQC/IIPC/5/29/2013/1610

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9830 Mayland Drive | Suite J | Richmond, VA | 23233 www.vhqc.org