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 [email protected] 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 2007Duration: 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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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
Compliance18
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 RampsTe
sting 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
2. Meet and discuss your aim for the collaborative3. Schedule first meeting AFTER June 24
4. Also, if you haven’t yet: Submit completed Team Grid Infection Preventionist complete CDI baseline
survey
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