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Evidence-based Care for the CDI patient Burnaby Hospital. Quality Forum 2013 February 28, 2013 Vancouver, B.C. Ivy Chow, Pharmacist Jan Chan, Registered Dietitian Judi Moscovitch, Quality Improvement & Patient Safety. Disclosure. We are unable to identify any potential - PowerPoint PPT Presentation
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Quality Forum 2013February 28, 2013
Vancouver, B.C.
Ivy Chow, Pharmacist Jan Chan, Registered Dietitian
Judi Moscovitch, Quality Improvement & Patient Safety
Evidence-based Care
for the CDI patientBurnaby Hospital
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DisclosureWe are unable to identify any potential
conflict of interest and have nothing to disclose
EXCEPTA strong bias towards ensuring quality,
safe care delivery to our patients.
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Key ObjectivesA. DemographicsB. Care and ManagementC. Recommendations
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HSMR Factor 724 CDI CasesQ1 2009 – Q3 2011/12
Age Over 80 60.8%Gender Female 51.8%
Urgent admit EHS 97.2%Transfer in Residential 17.5%
LOS 22 – 365 days
59.5%
Comorbidities
Cardiovascular
89.0%
A. Demographics
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B. Care and Management
RN review of 82 patient chartsPharmacy review of 65/82 charts
Unde
rsta
nd th
e Pa
tient
Jour
ney
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Antibiotic Usage
98.5% of patientswere on antibiotics
90 days prior totesting positive
for C difficile.
Safe
ty
30.8% of patients had an opportunity for a prescription or process change.
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BH CDI Pharmacy Study May 2012
80%
90%
100%Don't Tx Asymptomatic Bacteriuria
De-escalate Tx ASAP
Appropriate Empiric Choice
Appropriate Shortest Duration
Change/Remove Foley Catheter
Order cultures first
Antibiotic Practices
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Prevention
26.2% of patients
who were on Proton Pump
Inhibitors had an
opportunity for prescription
change.
Effec
tiven
ess a
nd S
afet
y
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What can we do? Reduce the use of inappropriate
antibiotics Review the need for Proton Pump
Inhibitors Refer patients to Pharmacy for
medication review
Med
icat
ion
Man
agem
ent
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Probiotics(Saccharomyces Boulardii)
Pharmacy and Nutrition literature indicates that Probiotics are not useful after diagnosis of CDI.
Some literature supports the use of probiotics for prevention of antibiotic-associated diarrhoea.
41 patients or 64.1% were prescribed Probiotics after CDI Diagnosis.
Effec
tiven
ess,
Efficie
ncy
and
Safe
ty
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Probiotics Saccharomyces Boulardii is
contra-indicated for immuno-compromised patients.
Of the 17 immuno-compromised patients in this study, 52.9% received Saccharomyces Boulardii.
Effec
tiven
ess a
nd S
afet
y
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What can we do? Review medical literature prior to
prescribing Saccharomyces Boulardii when: Patient has active CDI Patient is immuno-compromised Patient is in Critical Care Unit
Med
icat
ion
Man
agem
ent
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CDI Diarrhoea Secretory diarrhoea
Bowel rest (not eating) does not stop the diarrhoea
Increases active secretion>>> Protein loss >>> Increased risk of malnutrition
Effec
tiven
ess a
nd S
afet
y
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CDI and DietsNO literature to support diets that are: Lactose free Fibre free or Low fibre including formulas Pre-digested (elemental)
>>>Don’t limit intake
Effec
tiven
ess a
nd S
afet
y
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Diet Recommendation
Unless patient shows signs of Ileus, colonic perforation,
Toxic Megacolon or fulminant type of C.difficile
NPOOr Hold Tube Feeds
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BH CDI Chart Review May 2012
0%
20%
40%
60%
80%
100%Dietitian Consult
Appropriately Nourished
Avg. > 50% intake daily
Diet Changed due to CDI
Nutrition & Hydration
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What can we do? Refer malnourished patients to
Dietitian Educate the care team regarding
appropriate diets for CDI pts. AND
Remind and/or assist patients to wash
their hands before eating
Nut
riti
on C
are
and
Man
agem
ent
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Management of Nutrition & HydrationEff
ectiv
enes
s BH CDI Chart Review May 2012
0%
20%
40%
60%
80%
100%Weighed on Admission
Weighed when Diarrhea Started
% Meals Eaten Documented
In/Out Monitoring StartedIn/Out Monitoring Totalled
CDI Checklist
Bristol Chart initiated
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Effec
tiven
ess a
nd S
afet
y Nursing Management Doing well: Bristol Stool Chart Opportunity for Improvement:
Monitoring of indicators Documentation of nutrition & hydration Implementation of CDI Checklist
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What can we do? Implement a standardized
approach to Manage Nutrition and Hydration
Standardize and implement process for monitoring, treating and documenting CDI care.
Nur
sing
Car
e an
d M
anag
emen
t
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Effec
tiven
ess a
nd S
afet
y Interventions 55.4% prescriptions for CDI deviated from recommended
guidelines No comprehensive care pathway for patients not responding
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“CDI should be managed as a diagnosis in its own right,
with each patient reviewed daily regarding
fluid resuscitation, electrolyte replacement and nutrition review.
Monitor for signs of increasing severity of disease,
with early referral to ITU as patients may deteriorate
very rapidly.” Core Guidance 3.6 Clostridium difficile infection: How to deal with the
problem Department of Health, UK
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What can we do?
Implement Pre-Printed Orders for CDI treatment Review each case regularly for response to interventions
Dis
ease
Man
agem
ent
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We canwork as an integrated,
comprehensive Health Care TEAM! Physician Nurses and Aides Dietitian Pharmacist Infection Control Housekeeping Laundry Services
Who else is on your TEAM?Effec
tiven
ess a
nd S
afet
y
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1. Manage Medications Review Antibiotics, PPIs and use of
Probiotics2. Manage Nutrition and Hydration
Review and individualize plan Monitor intake and output
3. Manage the CDI disease process Pre-Printed Orders A Standardized Care Pathway
Consistent monitoring Weekly case review Integrated Team approach
C. RecommendationsCare & Management
Bundle
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C. RecommendationsCare & Management
BundleDon’t Forget!
4. Patient and Family Engagement
Patient hand-washing prior to eating
Follow Contact Plus precautions
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Where to Start
www.dh.gov.uk
www.ihi.org
www.saferhealthcarenow.ca
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For more information
please contact:
Jan Chan, Dietitian Practice Leader
Ivy Chow, Pharmacist
Judi Moscovitch, Consultant,
Quality Improvement & Patient Safety
What changecan you make
to drive QUALITY CDI care?
