C. Difficile Testing Protocol

Acute Care Hospital (Orthopedic Specialty Hospital)New York City

215 Beds

40 Operating Rooms

30,000 Procedures

352 Physicians

Caroline Donovan, RN, BSN, ONC- Infection Control Practitioner

Abegail Pangan, RN, MSN, CIC- Infection Control Practitioner

U.S. NEWS & WORLD REPORT 2017 – 2018 RANKINGS

What makes HSS Different?

▪ Orthopedic specialty hospital

▪ 30,000 procedures annually

▪ Hip replacements (HPRO) & Knee replacements (KPRO) –

▪ Only NHSN Reportable procedures

▪ 12,000 – 13,000 HPRO & KPRO procedures annually

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Clostridium Difficile Effects Patient Outcomes

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Clostridium Difficile Testing

▪ Acceptable Specimen▪ Loose or watery stool specimen▪ Suspected ileus caused by infection: verbal communication with lab

occurs prior to submission of sample

▪ Rejection Criteria▪ Specimens that are not liquid or soft▪ Specimens from infants under 1 year old should be discouraged▪ Specimen received greater than 24 hours after collection▪ Rectal swab specimens▪ “Test for cure” or testing from asymptomatic individuals

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Clostridium Difficile Laboratory Testing

▪ Stool Culture for toxin-producing C. diff (*Gold Standard)▪ Most accurate, but has slow turn around of up to 3 days; not clinically feasible

▪ Nucleic Acid Amplified Tests (NAAT) including Polymerase Chain Reaction (PCR)▪ High sensitivity and high specificity▪ May lead to false positive results and increase detection of colonizers

▪ Enzyme Immunoassay (EIA)▪ Rapid results, high specificity, but low sensitivity

▪ Glutamate Dehydrogenase (GDH)▪ GDH is an enzyme produced in large amounts with toxins A and B ▪ High sensitivity, but low specificity

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NHSN C. difficile Lab ID Event

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CDI-positive laboratory assay:All non duplicate positive laboratory test result for C. diff toxin A and/or B, (includes molecular and toxin assays) tested on an unformed stool specimen

Problem

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Antimicrobial Stewardship

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The C.difficile algorithm was created to help guide clinicians in the proper ordering of C. difficile testing. It is located in the C. difficile hospital policy.

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What Our EMR Implementation Allowed Us To Do…Infection Preventionist In House Staff

Isolation / Infection Mismatch report House census list- identifies isolation/ infection status

Laboratory based alert system that identifies and flag infection status

Positive test auto flagged in the patient’s infection banner

Automatic Contact isolation order is entered when test is ordered

Nurse will see the contact isolation order once C. diff test is entered-preemptive isolation

Infection Control Line listing of positive test in a time period

Allows communication of any increased trend of cases in a unit

Alert if C. diff test is ordered which allows early identification if appropriate C. diff testing is performed

Nurses avoid specimen collection if testing is inappropriate

Best Practice Advisory End user is informed of the C. diff testing algorithm

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Process and Governance

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EPIC replicated the algorithm in the form of a Best Practice Advisory (BPA) for prescribers to review when ordering testing.

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Selecting All Questions Reviewed is required in order to select the Accept button .

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Once accepted, both Clostridium Difficile Toxin and Contact Isolation Status display in the New Orders to be signed list. If a patient is already on Contact Precautions, only testing will populate.

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When the test is ordered, Infection Control Practitioners are alerted in the Isolation and Infection Census by the automatic Contact Isolation order and an alert seen in the C.diff Order column.

Staff members are able view the Isolation status on the EPIC banner.

The Infection Control Practitioners or Microbiology department adds the infection type once the test is positive in the infection tab to clarify for staff members why the patient is on Contact Isolation.

Staff members now see both Isolation and Infection on the EPIC banner.

C.difficile Tests Received by Microbiology Lab

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35

Tests

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Go Live for Algorithm: 03/16/17

Test Sent and Positive Results

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35

Tests

Positive

Hospital onset

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Go Live for Algorithm: 03/16/17

Better Patient Outcomes

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◦ Decreased unnecessary testing and treatmentEarly identification and prompt Contact IsolationIncreased communication of patient infection status to in house staffImproved active surveillance and reportingUtilization of Antibiotic Stewardship

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