C. Difficile Prevention Collaborative:
Learning and change in Massachusetts
September 2012
Susanne Salem-Schatz, Sc.D.
HealthCare Quality Initiatives
sss@hcqi.com
Sharon Benjamin, Ph.D.
Alchemy
Sharon@Sharonbenjamin.com
www.macoalition.org
1
Clostridium difficile infection (CDI)
• Anaerobic bacteria - spore producing bacillus
• Most common cause of infectious diarrhea in healthcare
facilities
• New strain appears to produce greater quantities of Toxin A and
B resulting in dire consequences in many cases
• Clinically manifests in a variety of forms from mild diarrhea to
toxic megacolon (rupture and sepsis) and subsequent death can
occur
• Risk factors
–
–
–
–
–
–
Elderly > 65 years of age more susceptible
Antimicrobial therapy
Advancing age
Tube feeding
Proton Pump Inhibitors (PPIs)
Extended length of stay
Clostridium difficile infection (CDI)
• Hospital-acquired, hospital-onset:
165,000 cases, $1.3 billion in
excess costs, and 9,000 deaths
annually
• Hospital-acquired, post-discharge
(up to 4 weeks): 50,000 cases,
$0.3 billion in excess costs, and
3,000 deaths annually
• Nursing home-onset: 263,000
cases, $2.2 billion in excess costs,
and 16,500 deaths annually
Clostridium difficile infection (CDI)
Precautions to prevent CDI are crucial to decrease morbidity and
mortality associated with this disease including:
• Effective hand-hygiene (alcohol hand sanitizer is not sporicidal
and is controversial in practice)
• Prompt testing and sharing of information
• Isolation precautions
• Communication
• Environmental cleaning including patient care equipment
MA CDI Prevention Collaborative 2010-2011:
Key features
 Statewide partnership and collaboration
 Multidisciplinary teams including representatives from infection prevention, quality,
clinical leadership, microbiology, pharmacy and environmental services;
 A common set of practice recommendations in the areas of surveillance testing,
isolation policies, hand hygiene, contact precautions, and environmental cleaning
and disinfection; with additional support for antibiotic stewardship
 3 statewide full day learning and sharing workshops and regional workshops featuring
expert presentations, highlighting accomplishments of Collaborative participants,
and teaching /practicing staff engagement strategies
 Improvement frameworks including the Model for Improvement (including PDSA, or
small tests of change), and culture change strategies such as Positive Deviance to
support staff engagement;
 Common measurement and reporting tools in Excel based on NHSN HAI definitions
MA CDI Prevention Collaborative 20102011
What hospitals did and how
MA CDI Prevention Collaborative 20102011
N=17
HA-CDI Reduction in MA Collaborative
CHANGE IN HA-CDI / 10,000 Patient Days
Baseline
Last 4 months % DECREASE
Jan-April '10 Sept-Dec '11
CASES
PT DAYS
RATE
356
401123
259
386629
8.88
6.70
MA CDI Prevention Collaborative 20102011
25%
One of 27 Stories
MA CDI Prevention Collaborative 20102011
Lessons Learned
Hospital #7
Improvement requires hard
work, time, & is supported by
building on long term
relationships and collaboration
Value of shared data to track
improvement and solve
problems
Value of an improvement
framework: aims, measures and
small tests of change
MA CDI Prevention Collaborative 20102011
15
10
5
0
Lessons Learned
Engaged front line staff make changes happen!
Adapt changes locally
Balance serious messages with
creative approaches to engage
staff and support culture of quality
MA CDI Prevention Collaborative 20102011
MA CDI Partnership Prevention Collaborative 2011-2012:
Key features
 Statewide partnership and collaboration
 Worked with clusters of 17 hospitals and 70 partnered long term care facilities (active engagement by
about 14 hospitals and 35 long term care facilities)
 Leveraged hospital expertise by encouraging cross facility efforts and coaching
 Multidisciplinary teams including representatives from infection prevention, quality, clinical
leadership, microbiology, pharmacy and environmental services;
 A common set of practice recommendations in the areas of surveillance testing, isolation policies, hand
hygiene, contact precautions, and environmental cleaning and disinfection; with additional support for
antibiotic stewardship
 2 statewide full day learning and sharing workshops and regional workshops featuring expert
presentations on CDI prevention practices, antibiotic stewardship, teaching /practicing staff
engagement strategies
 Improvement frameworks including the Model for Improvement (including PDSA, or small tests of
change), and culture change strategies such as Positive Deviance to support staff engagement;
 Common measurement and reporting tools in Excel based on NHSN HAI definitions
Small numbers and short timeframe make
it hard to document improvement
C difficile rate per 10,000 patient days
C difficile Rates per 10,000 Patient Days at Long Term Care Facilities
2.5
2.0
1.5
1.0
0.5
0.0
Aug 2011
Sep 2011
Oct 2011
Nov 2011
Dec 2011
Jan 2012
Feb 2012
Mar 2012
Facility CDI Rate/10,000 patient days
Partner Facility CDI Rate/10,000 patient days
Other Healthcare Facility CDI Rate/10,000 patient days
Community Acquired CDI Rate/10,000 patient days
Apr 2012
Stories of Success
Figure 2. CDI Cases by Facility of Origin
12
Number of Cases
10
8
6
4
2
0
CDI cases attributed to your facility
CDI cases attributed to partner facilities
CDI cases attributed to other healthcare facilities
Community-acquired CDI cases
Approaches used
What they said
• Value of activities with Partner Hospital
– 10 on a scale of 1-10
• Most innovative?
– CNAs loved the commode liners!
• What helped team work well together?
– Talking with the front line staff about what they think.
Showing rates of infection to department heads.
• Did new things to engage leadership, front line
staff and residents/families
They were part of an active cluster
And had active multidisciplinary teams
Milford Cluster
November 2011
Hospital
June 2012
Skilled Nursing
How LTCFs thought partner hospital
most helpful?
• We get many admissions from M Hospital. They always let us know
either before or at admission if a patient has c-diff infection.
• Providing information, education and demonstration of procedures
and what worked and did work for them.
• We use the hospital lab for our lab work;this is invaluable for
tracking and we are informed concerning any trends identified. The
hospital staff is available for consult, including the MD & Infection
Prevention Nurse.
• Sharing their expertise and information
What the hospital thought was valuable
• Monthly meetings where there is open
collaboration and sharing of knowledge.
Involvement of the MRMC Environment of Care
Department. They reached out to facilities with
help in engaging staff, providing education.
MRMC laboratory involvement with infection
prevention and control meetings at each facility.
Initial meet and greet informative breakfast
meeting was given by MRMC to "ALL" outside
long term care facilities. We closed each meeting
by each of us stating what would be our next
steps or project.
What helped cluster work well together &
fostered success?
• Willingness to communicate successes and
failures. There is truly a collaborative feeling
to our relationships. This, to a degree,
formalized what was already a solid working
relationship between the medical center and
facilities in our communities.
• "It takes a village." Working together as a
community increases our chances for success.
What we’ve learned
•
•
•
•
Relationship – centered approach
Engaging leadership and the front lines
Create opportunities for active learning
Combine existing evidence with opportunities
for discovery and reinvention
• Leverage organization’s self interest to create
broader communities of change
Where we struggle
• Dynamic tension between approaches that
involve direct coaching and the prevalent
learning collaborative models
• Balancing participant expectations and what
we know about adult learning
• How do we leverage multiple frameworks in a
resource-limited environment?