A Multidisciplinary Approach Reduces Clostridium Difficile Infections in Adult Surgical Patients

General Information

Institution Name: Duke University Hospital

Submitter Name: Megan C. Turner, MD, General Surgery Resident, Regina Woody Performance Services, and Christopher R. Mantyh, MD, FACS, Professor of Surgery

Name of Case Study: A Multidisciplinary Approach Reduces Clostridium Difficile Infections in Adult Surgical Patients

What Was Done?

Global Problem Addressed

Latrogenic Clostridium Difficile (CD) is a preventable infection leading to morbidity and mortality in the surgical patient.

CD can be used as a marker of surgical quality, and its prevention requires a multidisciplinary approach.^1-2

Identification of Local Problem

Duke University Hospital was identified as a high outlier for CD in the 2017 ACS NSQIP Interim Semi-Annual Report for all cases (data from October 2015 to September 2016) and for general, vascular, and urologic cases (data from January 2016 to December 2016).

How Was the Quality Improvement (QI) Activity Put in Place?

Context of the QI Activity

Duke University Hospital is a tertiary academic medical center with more than 900 beds. The surgical volume is 70,000 cases per year.

Following identification as a high outlier for CD, the department of surgery initiated a CD task force that included representation from surgeons, infectious disease specialists, pharmacy, and performance services.

Prior implementation of enhanced recovery protocols and surgical site infection prevention bundles had been successful in improving postoperative outcomes.³

This task force is not concurrent with any larger initiative. A parallel initiative in infection control is in place to decrease perceived penicillin allergies through confirmatory skin testing.⁴ This has been shown to decrease the use of antibiotics associated with CD. 

Planning and Development Process

Experts in CD prevention were identified as clinical champions and recruited for the task force.

• Surgeons
• Infectious Disease
• Pharmacy
• Administration
• Performance Services

Purpose of the CD task force:

• Analyze available data
  • ACS NSQIP CD occurrences July 2015-December 2016
  • NHSN CD rates
  • Institutional audits:
    • CD rates by ward
    • Antibiotic stewardship
    • Environmental cleaning
    • Hand hygiene
    • Personal protective equipment (PPE)
    • Testing/diagnostics
• Identify opportunities for improvement
• Implement strategies for reduction⁵
  • Collated from the literature by clinical champions
  • Proposals were presented to the group and decisions were made by consensus.

Protected time and financial incentives were not offered for this project.

Description of the Quality Improvement Activity

Following three meetings of the task force, the following interventions were initiated:

• Antibiotic Stewardship: Pharmacy, Infectious Disease, Technology Services, and Surgery
  • Two complex procedures, pancreatectomy and cystectomy, were identified as associated with non-guideline-adherent antibiotic practices and were high outliers for CD infection at our institution.
  • Electronic, evidence-based, perioperative antibiotic order sets were created
    • Consensus from Surgery, Infectious Disease, and Pharmacy
  • Electronic prescription defaults were implemented (Figure 1)
    • Cue prescribing physicians in real time to guideline-adherent antibiotic coverage and duration
  • Reduction in unnecessary fluoroquinolone exposure in the inpatient setting⁶

DMPPeriop: Duke Medical Pavilion Perioperative Unit. DN Periop: Duke North Perioperative Unit. These units represent the two bays of operating rooms used at our institution.

• Environmental Cleaning: Surgery, Administration, Infection Control Performance Services, Environmental Services⁷
  • Additional environmental service staff were requested through traditional hiring processes
  • Audits of the quality of terminal room cleans were implemented in 15 percent of rooms
  • Increased use of TRU-D®, an ultraviolet light disinfection system was implemented for all rooms with a known CD positive occupant (Figure 2)
    • Targeted unit use of TRU-D will include rooms on high-risk units once per month regardless of occupant CD status

• Hand Hygiene: Soap and water handwashing is the best method of prevention of human to human transmission; Infection Control, Performance Services
  • Improved signage for enteric precautions, with instructions for soap and water hand hygiene, were made available on surgical wards
  • Auditing of hand hygiene is completed with in-person monitoring
    • Increased monitoring was established in high-risk CD areas
      • Intensive care unit and surgical wards
• Personal Protective Equipment (PPE): Infection Control, Performance Services
  • Disposable gowns and gloves are made available outside CD patient rooms
  • Auditing of compliance by providers is done on high-risk units
• Diagnostic Stewardship: Infectious Disease, Laboratory Services, Surgery, Technology Services
  • Prior to the intervention, all stool samples sent for diagnosis were tested with polymerase chain reaction (PCR)
  • Alternatives exist, including antigen and antibody testing
    • Our institution elected to continue a PCR-based diagnostic practice
    • An electronic best practice advisory pop-up was established to reduce unindicated CD testing (Figure 3)
    • The pop-up is triggered when a CD diagnostic test is ordered when the patient has been receiving laxatives

• Routine Data Feedback: Performance Services, Surgery
  • ACS NSQIP and NHSN CD infection reports
    • Disseminated to surgical division heads
• Audit systems are in place:
  • Hand hygiene
  • PPE use
  • Quality of terminal room cleans.
• These scores are disseminated to surgical and quality leadership
• Performance services organizes data representation and visualization for improved interpretation and dissemination (Figure 4)

• 6W: Surgical Intensive Care Unit, 2100, 2300, 6300 surgical wards.
  
  
• Education: Pharmacy, Surgery, Infectious Diseases, Performance Services
  • Surgical Grand Rounds, Urology Grand Rounds (Figures 5 and 6)
    • Surgeon champions, ACS NSQIP surgeon champion
    • Infectious disease specialists
    • Pharmacy
    • Performance services

• The department of surgery grand rounds is attended by more than 100 members of the surgical staff.
• Urology grand rounds is attended by more than 30 members of the urology staff.

Resources Used and Skills Needed

Staff

Surgeon Champions:

• Christopher R. Mantyh, MD, surgical champion
• Megan Turner, MD, data collection and analysis
• Wendy Webster, MBA, data analysis

Infectious Disease and Infection Control:

• Becky Smith, MD, infectious disease expert
• Rebekah Wrenn, PharmD, antibiotic expert
• Kirk Huslage, MSPH, BSN, RN, data collection, infection control specialist

 Performance Services:

• Regina Woody, RN, SCR data source and analysis

 Task force members attend quarterly meetings and provide feedback to their respective divisions. 

Costs

Costs incurred have been absorbed within the operations budget of each department. No additional funding has been used in this quality initiative.

What Were the Results?

Overall Results

The primary metric of success following the implementation of the quality initiative was the ACS NSQIP observed CD rate.

• Initial high-outlier status at 1.19 percent in October 2016

Reduced to 0.93 percent in September 2017 (Figure 7)

Secondary Outcomes

• Decreased fluoroquinolones prescriptions and number of days of therapy by 9 percent
• Decreased CD testing for patients on laxatives from 23 percent prior to the BPA initiation to 7 percent
• 58 percent increase in terminally cleaned rooms with the TRU-D technology

Setbacks

Given the multidisciplinary nature of this quality initiative, several barriers occurred in implementation.

Environmental Services

• Established contractual agreements
  • Limited flexibility with increasing staff numbers and hours as well as overall work distribution
  • Difficulty purchasing additional TRU-D® technology

Microbiologic Laboratories

• Current policy is to not speciate mixed flora urine samples
• Unable to narrow antibiotic coverage
  • Specific barrier to antibiotic stewardship on urologic service
  • Ongoing conversations are being held between stakeholders to improve policies and support work flow

NHSN data is by default reported by admitting service.

• Transitioning to reporting formats by surgical ward, intensive care unit versus stepdown versus ward, has been essential to create a heat map of locations for targeted resource allocation

Next Steps

Outpatient antibiotic use

• Monitoring
• Improving electronic defaults

Creation of CD prevention dashboard

• Display quality measures in one electronic location
• With easy to interpret graphics

As with all quality initiative implementation projects, consistent feedback to stakeholders by champions is essential to maintain gains achieved over the last year.

Developing a pathway to sustainability includes automating data feedback, managing defaults to reflect current literature and practice patterns, and fostering innovation for adherence to established protocols.

Cost Savings

Cost savings have not been a measured outcome for this quality initiative. Estimates based on the literature are available as described below; however, data specific to our institution were not collected.

• New diagnoses of CD are estimated to generate $24,205 in costs in six months of follow-up⁸
• CD diagnosis is estimated by CMS to generate $5,682-$8,096 in non- chargeable costs¹

Specific costs for antibiotics as well as cost savings are variable pending reimbursement metrics. The ultraviolet device costs are variable based on use within a study and total number of staff trained to use the device. The environmental services budgets are not publicly available.

Tips for Others

• Identification of areas of improvement is important in creating and implementing targeted interventions for management of CD.
• Use of ACS NSQIP and NHSN metrics are essential.
• Institutional level data can provide increased granularity by which to direct interventions.
• Identify multidisciplinary champions by department and division with support from departmental leadership.
• Targeted feedback by division is essential for supporting changes in work flow, changes to defaults, and developing a culture of evidence-based medicine and guideline adherence.
• Data visualization services are instrumental in helping busy providers deficiencies and implementation success.
• Using these mechanisms, institutions can implement a CD reduction quality initiative to improve the care of the patients they serve.

References

1. Hospital Acquired Condition Reduction Program 2015. Updated November 25, 2015. Available at: https://www.cms. gov/Medicare/QuaIity-1nit iatives-Patient-Assess ment-1nstruments/VaIue-Based-Programs/HAC/H ospita1-Acquired­ Conditions.htmI. Accessed June 26, 2018. 
2. McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2018;66(7):987-994. 
3. Keenan JE, Speicher PJ, Thacker JK, Walter M, Kuchibhatla M, Mantyh CR. The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings. JAMA surgery. 2014;149(10):1045-1052. 
4. Unger NR, Gauthier TP, Cheung LW. Penicillin skin testing: potential implications for antimicrobial stewardship. Pharmacotherapy. 2013;33(8):856-867 
5. Barker AK, Ngam C, Musuuza JS, Vaughn VM, Safdar N. Reducing Clostridium difficile in the Inpatient Setting: A Systematic Review of the Adherence to and Effectiveness of C. difficile Prevention Bundles. Infection control and hospital epidemiology. 2017;38(6):639-650 
6. Dingle KE, Didelot X, Quan TP, Eyre DW, Stoesser N, Golubchik T, et al. Effects of control interventions on Clostridium difficile infection in England: an observational study. The Lancet Infectious Diseases. 2017;17(4):411-421. 
7. Sitzlar B, Deshpande A, Fertelli D, Kundrapu S, Sethi AK, Donskey CJ. An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms. Infection control and hospital epidemiology. 2013;34(5):459-465. 
8. Zhang D, Prabhu VS, Marcella SW. Attributable Healthcare Resource Utilization and Costs for Patients with Primary and Recurrent Clostridium difficile Infection in the United States. Clinical Infectious Diseases. 2018;66(9):1326-1332.