C. Difficile Prevention Collaborative:Hospital Team Kick-off

Audio Conference Call June 2, 2010

www.macoalition.org

C. Difficile Prevention CollaborativeSenior Leaders Call: Agenda

 

                                                                              

 Introduction to C. Difficile Prevention Collaborative

Driving Unprecedented Reduction in Clostridium difficile in Acute Care using a Breakthrough Series Collaborative Model

Susanne Salem-Schatz, Sc.D.Collaborative Director

Maxine PowerImprovement AdvisorSalford Royal NHS Hospitals Trust

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Context of the Collaborative Keeping patients safe Local and National Priority

Coalition, MHA, DPH Priority CDC subsidy: American Recovery and

Reinvestment Act ICU Safe Care Initiative/CUSP – Central Line

Infections Needs assessment C. Difficile

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Collaborative Teams Bay State Medical Center Berkshire Medical Center Brigham and Women’s Hospital Cape Cod Hospital Clinton Hospital Emerson Hospital Fairview Hospital Falmouth Hospital Franciscan Hospital for Children Harrington Memorial Hospital HealthAlliance Hospitals, Inc. Marlborough Hospital Massachusetts Hospital School Mercy Hospital Merrimack Valley Hospital

MetroWest Medical Center Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Hospital New England Sinai Hospital Noble Hospital Northhampton VA Medical Center Shriner’s Hospital for Children Southcoast Hospitals Group Spaulding Rehabilitation Hospital St. Vincent’s Hospital Tewksbury Hospital UMASS Memorial Hospital Wing Memorial Hospital & Medical Ctrs.

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Overview of the Collaborative Leadership engagement – Executive Sponsor Multidisciplinary team & pilot unit

Beyond the usual suspects Focus on the what and the how

Audioconferences – Expert presentations and coaching calls 3 Learning sessions – June 24 Regional coaching sessions & individual support

Measurement & brief monthly reporting

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Driving Unprecedented Reduction in Clostridium difficile in Acute Care using a Breakthrough Series Collaborative Model

Maxine PowerImprovement AdvisorSalford Royal NHS Hospitals TrustMaxine.power@srft.nhs.uk 6

Clostridium difficile (C. difficile)

C. difficile is a spore forming bacterium Major cause of antibiotic associated diarrhoea Spores shed in the stool

Difficult to eradicate from patients; relapses common Alcohol hand gel is ineffective

Spores survive up to 70 days in the environment Spores can be re-ingested and re-infect Primary source of transmission:

hands environmental surfaces Picture

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Treatment and remission

First episode Discontinuation of current antibiotic therapy. Discuss with Microbiologist. Replacement of fluid and electrolytes. Metronidazole PO 400mg TDS for 10 days.

Evaluate response to therapy at days 6-7 . Symptoms not resolving or worsening, then stop metronidazole Commence oral vancomycin PO 125mg QDS for 14 days.

30% will relapse within 30 days 20% will have repeated relapses

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Evidence based management

Hand hygiene

Isolation & containment

Contact Precautions

Environmental cleaning with hydrogen peroxide

Restricted use of broad spectrum antibiotics

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The problem at Salford Royal (2007)

C. difficile incidence was increasing 027 strain had been isolated 4th Highest incidence in the North West of England 50 cases per month 30% on five medical wards Consequences:

Seen as ‘inevitable and unavoidable’ by staff Morbidity Mortality Increased costs at additional cost of £4715 per patient

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Antibiotic Stewardship

February 2007 – protocols developed & implemented New emphasis on caution ‘wait and see’ Cultures first Structured for presenting conditions Severity scores mandatory e.g. CURB Cephalosporins and Quinalones removed and

accessible only to senior team or via microbiology Antibiotic pharmacist employed to round 60% compliance overall

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What else can we do?.....

Set a clear, time limited, measurable aim Provide clarity about ‘what to do’ Offer time Offer leadership support Support teams with measurement and feedback Provide improvement expertise Provide a structured & safe environment to test and

change

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Aim

To reduce the incidence of clostridium difficile

in the elderly care units by 50% by April 2008

Start date: April 1st 2007

Duration: one year

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Why This Is a Great Aim Statement

What Reduce incidence of c. difficile

By When April 2008

For Whom Elderly care units

How Much By 50%

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Aim – Why it matters

Establishes clear, unambiguous intent to improve Time a team spends working on its purpose is a highest

predictor of success Balancing reach with feasibility: inspiring without discouraging Our recommendations

Minimum: 30% reduction CDI in 18 months Maximum: elimination of HA-CDI

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Our Collaborative Aim

30% reduction in C. difficile infection per 10,000 hospital discharges by

December, 2011

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A Breakthrough Series Collaborative?

www.ihi.org 17

Driver Diagram (Causal Pathway) of Factors influencing C. difficile

Aim=

50% reduction in

C.difficile

Early identification & containment

Habits & patterns

Environment

Antibiotic use

Patient alert to risk

Staff alert to risk

Isolation

Hand hygiene

Rings / nails / clothing

Rounds (medical) / barrier procedures

Information

Cleaning

Waste disposal

Standardised protocols

Compliance

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Measures

Primary Outcome Measure: Incident cases of C. difficile

Process Compliance: Hand hygiene compliance Antibiotic prescribing compliance

Balancing Measure: Sepsis

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Balanced Set of Measures Outcome measures

•How is system performing?•What are results?

Process measures•Are system parts/steps performing as planned?

Balancing measures •Are changes designed to improve one part causing problems in another?

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MA C. diff Collaborative Measures

Primary Outcome Measure: Incident cases of Health care acquired C. difficile per 10,000 patient days

Process Measures Choose your own Link to changes you are making Guidance and tools for tracking

Balancing Measures Link to process changes

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Improvement skills (LS1)

Model for Improvement Plan do Study Act (PDSA) Measurement Reliability Science

Outcome = 1st test of change

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Multiple PDSA Cycle RampsTes

ting an

d adap

tation

A PS D

A PS D

A PS D

D SP A

A PS D

A PS D

A PS D

D SP A

A PS D

A PS D

A PS D

D SP A

A PS D

A PS D

A PS D

D SP A

Early identification

Habits &patterns

Antibioticprotocols

Environment

Change Concepts 23

What we learned?

Measures Innovation Extranet Sharing tests of change

Adopt Adapt Abandon

Celebrate Success +++

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Debbie’s story – success or failure?

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Make the desired the default

Clean unless proven dirty Dirty unless proven clean

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Innovation concepts

‘Vuja de’‘A sense of seeing something for the first time

even if you have seen it many times before’

Washing patients Washing ‘at risk’ patients27

First Focus - Select ONE focus area- Use small scale tests

Ideas and Hunches

Study

Act

Do

Plan

Improvement

Test in One Process

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PDSA Tip #1: Scale Down Years Quarters Months Weeks Days Hours Minutes Number of pts

“Drop 2”

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PDSA Tip #2: “Oneness”

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One test is rarely enoughThe more test cycles completed, the more teams learn The more teams learn, the more capable they are of making improvements

In our experience…

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Project Management :Sharing and Spread

L8 L4 L2 L3 L5

Identification & containment

√ √ √ √

Habits & patterns

√ √ √ √ √

Antibiotics √

Environment √

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•1.15 (95% CI 1.03 to1.29) cases per 1000 occupied bed days at baseline •0.64 (95% CI, 0.49 to 0.79) cases per 1000 occupied bed days post collab

1 New Antibiotic Policy

2 Learning Session 1

3 Learning session 2

4 Learning Session 3

5 Scale up and Spread

6 Learning Session 4

7 Learning Session 5

8 Learning Session 6

9 Second Summit

Baseline Collaborative Spread

The shift in the mean identified in August 2007 represents a 56% reduction.

Non Collaborative Wards

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1 New Antibiotic Policy

2 Learning Session 1

3 Learning session 2

4 Learning Session 3

5 Scale up and Spread

6 Learning Session 4

7 Learning Session 5

8 Learning Session 6

9 Second Summit

Baseline Collaborative Spread

Collaborative Wards

The shift in the mean identified in April 2007 represents a 73% reduction.

•2.60 (95% CI 2.11 to 3.17) cases per 1000 occupied bed days at baseline •1.91(95% CI 1.44 to 2.38) cases per 1000 occupied bed days post collab

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Thanks to………….

Patient and families for their cooperation & patience Staff of L2, L3, L4, L5 & L8 Executive team Don Goldmann & Fran Cook SRFT Infection Control Team Sandy Murray & Bob Lloyd

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C. Difficile Prevention Collaborative Next Steps

1. Sign your team up for June 24 kick-off meeting at:http://www.regonline.com/cdiffpreventioncollaborativeteamworkshop

2. Meet and discuss your aim for the collaborative3. Schedule first meeting AFTER June 244. Also, if you haven’t yet:

Submit completed Team Grid Infection Preventionist complete CDI baseline

survey

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