C. Difficile Prevention Collaborative: Hospital Team Kick-off

1. C. DifficilePrevention Collaborative:Hospital Team Kick-off Audio Conference Call June 2, 2010 www.macoalition.org

2. C. Difficile Prevention CollaborativeSenior Leaders Call: Agenda Susanne Salem-Schatz, Sc.D. Collaborative Director Maxine Power Improvement Advisor Salford Royal NHS Hospitals Trust Introduction to C. Difficile Prevention Collaborative Driving Unprecedented Reduction in Clostridium difficile in Acute Care using a Breakthrough Series Collaborative Model

3. 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

4. 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.

5. 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

6. Driving Unprecedented Reduction in Clostridium difficile in Acute Care using a Breakthrough Series Collaborative Model Maxine Power Improvement Advisor Salford Royal NHS Hospitals Trust Maxine.power@srft.nhs.uk

7. 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

8. 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

9. Evidence based management • Hand hygiene • Isolation & containment • Contact Precautions • Environmental cleaning with hydrogen peroxide • Restricted use of broad spectrumantibiotics

10. 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

11. 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

12. 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

13. 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

14. 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%

15. 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

16. Our Collaborative Aim 30% reduction in C. difficile infection per 10,000 hospital discharges by December, 2011

17. A Breakthrough Series Collaborative? www.ihi.org

18. Driver Diagram (Causal Pathway) of Factors influencing C. difficile Patient alert to risk Staff alert to risk Isolation Early identification & containment Aim= 50% reduction in C.difficile Hand hygiene Rings / nails / clothing Rounds (medical) / barrier procedures Habits & patterns Information Cleaning Waste disposal Environment Standardised protocols Compliance Antibiotic use

19. Measures Primary Outcome Measure:         Incident cases of C. difficile Process Compliance:           Hand hygiene compliance Antibiotic prescribing compliance Balancing Measure: Sepsis

20. 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?

21. 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

22. Improvement skills (LS1) • Model for Improvement • Plan do Study Act (PDSA) • Measurement • Reliability Science • Outcome = 1st test of change

23. Multiple PDSA Cycle Ramps P P P P A A A A D D D D S S S S S S S S D D D D A A A A P P P P A A A A P P P P S S S S D D D D P P P P A A A A D D D D S S S S Testing and adaptation Early identification Antibiotic protocols Habits & patterns Environment Change Concepts

24. What we learned? • Measures • Innovation • Extranet • Sharing tests of change • Adopt • Adapt • Abandon • Celebrate Success +++

25. Debbie’s story – success or failure?

26. Make the desired the default Dirty unless proven clean Clean unless proven dirty

27. 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’ patients

28. Act Do Study Test in One Process Improvement Plan • First Focus • Select ONE focus area • Use small scale tests Ideas and Hunches

29. Years Quarters Months Weeks Days Hours Minutes Number of pts “Drop 2” PDSA Tip #1: Scale Down

30. PDSA Tip #2: “Oneness” 1

31. In our experience… • One test is rarely enough • The more test cycles completed, the more teams learn • The more teams learn, the more capable they are of making improvements

32. Project Management :Sharing and Spread

33. Non Collaborative Wards 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 • 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 Baseline Collaborative Spread The shift in the mean identified in August 2007 represents a 56% reduction.

34. Collaborative Wards • 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 Baseline Collaborative Spread 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 The shift in the mean identified in April 2007 represents a 73% reduction.

35. 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

36. C. Difficile Prevention Collaborative Next Steps • Sign your team up for June 24 kick-off meeting • Meet and discuss your aim for the collaborative • Schedule first meeting AFTER June 24 • Also, if you haven’t yet: • Submit completed Team Grid • Infection Preventionist complete CDI baseline survey