Transcript C. Difficile Prevention Collaborative: Hospital Team Kick-off

C. Difficile Prevention Collaborative:
Hospital Team Kick-off
Audio Conference Call
June 2, 2010
www.macoalition.org
C. Difficile Prevention Collaborative
Senior Leaders Call: Agenda
Introduction to C. Difficile Prevention
Collaborative
Susanne Salem-Schatz, Sc.D.
Collaborative Director
Driving Unprecedented Reduction in
Clostridium difficile in Acute Care
using a Breakthrough Series
Collaborative Model
Maxine Power
Improvement Advisor
Salford Royal NHS Hospitals Trust
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Context of the Collaborative
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Keeping patients safe
Local and National Priority
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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
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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
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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
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Leadership engagement – Executive Sponsor
Multidisciplinary team & pilot unit
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Beyond the usual suspects
Focus on the what and the how
 Audioconferences –
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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 Power
Improvement Advisor
Salford Royal NHS Hospitals Trust
[email protected]
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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
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Hand hygiene
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Isolation & containment
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Contact Precautions
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Environmental cleaning with hydrogen peroxide
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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?.....
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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
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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
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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
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Driver Diagram (Causal Pathway) of Factors
influencing C. difficile
Patient alert to risk
Early identification
& containment
Staff alert to risk
Isolation
Hand hygiene
Aim=
Habits & patterns
Rings / nails / clothing
Rounds (medical) / barrier
procedures
50%
reduction in
C.difficile
Information
Environment
Cleaning
Waste disposal
Antibiotic use
Standardised protocols
Compliance
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Measures
 Primary Outcome Measure:
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Incident cases of C. difficile
 Process Compliance:
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Hand hygiene compliance
Antibiotic prescribing compliance
 Balancing Measure:
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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:
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Incident cases of Health care acquired C. difficile
per 10,000 patient days
 Process Measures
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Choose your own
Link to changes you are making
Guidance and tools for tracking
 Balancing Measures
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Link to process changes
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Improvement skills (LS1)
 Model for Improvement
 Plan do Study Act (PDSA)
 Measurement
 Reliability Science
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Outcome = 1st test of change
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Multiple PDSA Cycle Ramps
Early
identification
Habits &
patterns
Antibiotic
protocols
Change Concepts
Environment
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What we learned?
 Measures
 Innovation
 Extranet
 Sharing tests of change
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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’ patients
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Test in One Process
Improvement
Act
Plan
Study
Do
First Focus
- Select ONE focus area
- Use small scale tests
Ideas and Hunches
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PDSA Tip #1: Scale Down
 Years
 Quarters
 Months
 Weeks
 Days
 Hours
“Drop 2”
 Minutes
 Number of pts
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PDSA Tip #2: “Oneness”
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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
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Project Management :
Sharing and Spread
L8
Identification &
containment
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Habits &
patterns
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Antibiotics
Environment
L4
L2
L3
L5
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Non Collaborative Wards
•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
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New Antibiotic Policy
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Learning Session 1
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Learning session 2
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Learning Session 3
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Scale up and Spread
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Learning Session 4
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Learning Session 5
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Learning Session 6
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Second Summit
Baseline
Collaborative
Spread
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The shift in the mean identified in August 2007 represents a 56% reduction.
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
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New Antibiotic Policy
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Learning Session 1
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Learning session 2
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Learning Session 3
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Scale up and Spread
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Learning Session 4
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Learning Session 5
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Learning Session 6
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Second Summit
Baseline
Collaborative
Spread
The shift in the mean identified in April 2007 represents a 73% reduction.
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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
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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
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