Patient Safety Summit 2014

C-Diff Environmental Screening Study

Dr. Sushma Sharma Director, Community, Population/Public Health DFWHC Foundation Irving, TX 75062

Dr. Kimberly Fulda Assistant Professor of Family Medicine Texas Prevention Institute Associate Director, Primary Care Research Center Interim Executive Director, NorTex UNTHSC, Fort Worth, TX 76107

C-Diff Environmental Screening Study

This study was funded by DFWHC Foundation Hospital Engagement Network, under contract with the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contract Number HHSM-500-2012-0025 Hospital Engagement Network Contractor for Partnership for Patients Initiative.

Clostridium difficile (C-Diff) 

Greek kloster (κλωστήρ), "spindle“ and Latin difficile, "difficult, obstinate”

www.bioquellus.com

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Why it is Important?

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The estimated cost per infection ranges from $6,000 - $9,000.

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The estimated total cost per year ranges from $1 billion - $1.6 billion.

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The average hospital cost for patients with C. difficile is nearly three times higher than patients without C. difficile ($23,190 vs. $8,860).

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Symptoms of C-Diff Infection

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Adults: significant diarrhea, recent antibiotic exposure, abdominal pain, fever, and a distinctive foul stool odour

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Children: watery diarrhea, fever, loss of appetite, nausea, and/or abdominal pain

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Causes 

Exposure to antibiotics

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Exposure to a contaminated environment

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Acid suppressing medications

Transmission 

Person to person by the “fecal-oral route” through spores

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Literature Review What has been done?

1983 J of Clinical Pathology : Malamou-Ladas et al. 2008 J of Hospital Infection: Shapey et al. 2007 Am J Infect Control 2007: Dubberke et al.

2008 Infection Control and Hospital Epidemiology: Dubberke et al. 2012 Indian J of Medical Biology: Vaishnavi and Singh. 2013 Am College of Gastroenterology released C-Diff Recom.

2013 BMC infectious Diseases: Faires et al. 2014 Current Topics in Medical Chemistry: Tsutsumi et al. 2014 Trends Microbiol: Sorg et al.

+ C-Diff Environmental Screening Team 

Investigators    

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Jerry Simecka, PhD – Professor in Cell Biology and Immunology Frank Filipetto, DO – Associate Professor in Family Medicine, Associate Dean of Texas College of Osteopathic Medicine

Laboratory Personnel  

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Kimberly Fulda, DrPH – Interim Executive Director of NorTex, Assistant Professor in Family Medicine Joon Lee, PhD – Assistant Professor in Environmental and Occupational Health Sciences

Mark Pulse, MS Phung Ngyuen

Research Coordinators / Assistants      

Anna Espinoza, MD Michelle Lee, MS Vanida Prieto, RN Briar Deen Charles Langat Erica Resendes

+ Study Details Participating Facilities: 33

Hospitals 19

Nursing Homes and LTACs 3 Sampling Rounds 1 2 3

No. of samples collected 263 224 217 704

Clinics 11 (Urban 6 &Rural 5) No. of samples tested 256 224 217 697

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Design and Methodology

Environmental Swabbing of 7 selected sites • • • • • • •

computer keyboards light switches window blind wands/ curtains bedrails door knobs restroom sink handles and faucet toilet handle

Education Survey

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Environmental Swabbing

+ Environmental Swabbing

+ Environmental Screening Sample Processing at Dr. Simecka and Dr. Lee’s Labs

+ Environmental Screening Sample Processing at Dr. Simecka and Dr. Lee’s Labs

+ Results : Environmental Screening C-diff Prevalence by Type of Facility Health care facility No. of samples

No. of samples No. of positive % C-diff Samples Tested Prevalence

Clinics (11)

231

231

16

6.93

Hospitals (19)

385

378

5

1.32

Long-term care (3)

63

63

2

3.17

Total (33)

679

672

23

3.42

+ Results: Environmental Screening C-diff Prevalence by Sampling Site (33 Facilities) Sampling site Bed rails Door knob Key boards Light switches Restroom sink handles & faucet Toilet handles/ push button Window blind wands/curtain

No. positive samples

% C-diff Prevalence

No. of samples

No. of samples tested

101 100 101 101

100 99 100 100

6 4 5 0

6.00 4.04 5.00 0.00

100

99

4

4.04

100

99

3

3.03

101 704

100 697

2 24

2.00 3.44

+ Results: Environmental Screening C-diff Prevalence by Sampling Site (Hospitals) Sampling site Bed rails Door knob Key boards Light switches Restroom sink handles & faucet Toilet handles/ push button Window blind wands/curtain

No. positive samples

% C-diff Prevalence

No. of samples

No. of samples tested

55 55 55 55

54 54 54 54

0 2 0 0

0.00 3.70 0.00 0.00

55

54

2

3.70

55

54

0

0.00

55 385

54 378

1 5

1.85 1.32

+ Results: Environmental Screening C-diff Prevalence by Sampling Site (Clinics) Sampling site Bed rails Door knob Key boards Light switches Restroom sink handles & faucet Toilet handles/ push button Window blind wands/curtain

No. positive samples

% C-diff Prevalence

No. of samples

No. of samples tested

33 33 33 33

33 33 33 33

6 2 5 0

18.18 6.06 15.15 0.00

33

33

1

3.03

33

33

1

3.03

33 231

33 231

1 16

3.03 6.93

+ Results: Education Survey All 33 facilities (Hospitals 19, Clinics 11, Nursing Homes 3) Does your clinic / hospital have a policy on infection control?

28(84%) Yes

Does your clinic/hospital facilitate training / education to staff on infection control? 27(82%) Yes Does your clinic / hospital have guidelines for staff for cleaning processes, personal hygiene and hand washing techniques, and antibiotic stewardship? 30 (91%) Yes Does your clinic / hospital have any specific guidelines for C-Diff infection prevention? 23 (70%) Yes

+ Results: Education Survey All 33 facilities (Hospitals 18, Clinics 11, Nursing Homes 4) How often does your clinic/hospital clean (disinfect) these surfaces (every day / every week)? Sites Light switches Door knobs Window blind wands / curtains Restroom commode Handles Sink handles Keyboards Bedrails

Every day

Every week

60.60% 60.60% 24.20% 90.90% 90.90% 54.50% 69.70%

6.10% 30.30% 30.30% 9.10% 6.10% 21.10% 3.00%

C-Diff Positive lab Results 0.00% 4.04% 2.00% 3.03% 4.04% 5.00% 6.00%

+ Results: Education Survey Hospitals 19, Clinics 11, Nursing Homes 3 How often does your clinic/hospital clean (disinfect) these surfaces (every day / every week / every month / every 6 months / never)? Sites Light switches Door knobs Window blind wands / curtains Restroom commodes Sink handles Keyboards Bedrails

Clinics every day every week 27.30% 54.50% 27.30% 63.60%

Hospital every day every week 78.90% 10.50% 78.90% 10.50%

Long term care every day every week 66.70% 33.30% 66.70% 33.30%

9.10% 81.80%

27.30% 18.20%

36.80% 94.70%

31.60% 5.30%

0 100%

33.30% 0

81.80% 27.30% 27.30%

9.10% 36.40% 9.10%

94.70% 78.90% 89.50%

5.30% 5.30% 0

100% 0 100%

0 66.70% 0

+ Conclusions Environmental Screening and Survey • Study identifies the scope for education and awareness regarding CDiff infection prevention in the community as well as in health care settings. • Study suggests more robust cleaning and infection control measure to prevent C-Diff infection through surfaces like key boards, bedrails, door knobs etc.

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Next Steps 

We will implement an education campaign that will focus on clinical personnel and the public.

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All sites will be visited three more times this Fall to collect environmental samples.

Patient Safety Summit 2014