Transitions of Care in Patients With Recurrent C. Diff: An Opportunity for Collaboration Among Community, Health System Pharmacists

Background

It is estimated that approximately 450,000 cases of Clostridioides difficile infection (CDI) occur each year in the United States and approximately 25% of patients treated for an initial episode will experience recurrence. In patients having 3 or more recurrent episodes, the rate increases to 40%–65% of patients, with a cycle of multiple recurrences in a single patient contributing to the complexity of care.¹

These patients suffer with the symptoms of watery diarrhea of up to 10-15 times per day, abdominal cramping and pain, fever, loss of appetite, swollen abdomen, and dehydration leading to possible kidney dysfunction. When CDI persists, there may be severe intestinal inflammation and enlargement of the colon. This can lead to sepsis and admission to the intensive care unit or surgical intervention.

Patients with active disease or those suspected of having CDI will receive treatment and their care will be managed across multiple health care settings, including many different levels of health care workers. Pharmacists are particularly well positioned and can communicate across the continuum of care to reduce and avoid recurrence and direct those with recurrentCDI (rCDI) to the most appropriate provider. Implementing a well-structured transition of care (ToC) process can ease the burdens on the health care system, as well as on patients and their families, and improve patient outcomes.

Identify Patients With CDI Recurrence During Transition Of Care

A focus on medication management during ToC is known to improve health outcomes.On an ongoing basis, pharmacists reconcile discrepancies in medication therapy that translate into improved outcomes and reduced readmissions.²

Accurate and timely communication can become a critical component of this care transition. Data show that initiation of these ToC programs can improve communication between inpatient and outpatient pharmacists and caregivers.

Based on the patients’ journey and course of disease, one can easily understand how CDI is no exception for the ToC process to improve outcomes in these patients. Pharmacists are extensively involved in the care transitions workflow and have the opportunity to make a real impact. Table 1 outlines some ideal practices.

Table 1. Specific Communications on CDI Between Pharmacists During Care

Key Components: Education of Patients Based on Their Current CDI Disease Journey

The main foci for the success of the ToC process for pharmacists to improve medication management during a CDI episode. First, patient education on CDI prevention, treatment, and recurrence must become the standard. Each patient’s or their caregiver’s understanding of the disease must be assessed individually during counseling.

Second, communication and collaboration among providers should occur with a special emphasis on inpatient and ambulatory care pharmacists. These communications should focus on:

1. Understanding patients’ educational needs from handwashing to what to do if recurrence evolves.
2. Initiation of appropriate therapy that allows for feasibility of the patient to be adherent. This is including, but not limited to, assessment of the frequency and intended duration of the therapy, as well as the anticipated cost of the therapy.
3. Completion of treatment in accordance with guidelines despite any obstacles such as insurance denials/co-pays, patient adherence, and stopping other medications, such as proton pump inhibitors.
4. The outcomes of patients need to be followed closely over time to monitor for recurrence and recommend or refer patients for management.

Frequently, health care-acquired CDI patients are discharged into the home environment or are followed loosely by transitional care services.³

This means that communication and education around the day of discharge is especially important. In electronic medical record systems, the patient’s primary pharmacy is listed so contact information is readily available for the inpatient or transitions of care pharmacists to contact the outpatient pharmacy provider.

Some have recommended a “hand-off” or pharmacist discharge care plan to facilitate the coordination of medication management between the hospital and community pharmacist. This has been suggested to provide continuity so that the community pharmacist has a list of actual or potential medication-related problems to follow-up on with the patient or other health care providers. It also provides the community pharmacist with patient information that they would not normally have access to.⁴

During this handoff, discussing education needs of the patient is of critical importance. An understanding of the impact of recurrence is vital to the management of CDI. It has been suggested that one question during medication counseling that can assess patients understanding could be, “Who would you call if you have diarrhea, nausea, abdominal pain, or vomiting that gets worse after you finish your antibiotics?”

This would demonstrate that they understand what to do on the first signs of recurrence. Ensuring patients know what to do at signs of recurrence will allow for earlier intervention before patients become dehydrated and too weak to be managed at home. Patient education during the transition of care process for CDI remains critical.

Miller and Schaper found that uncoordinated transitions from the inpatient setting to the home environment created hardships for patients and families when a readmission occurred as a result of failed inpatient discharge processes. The authors noted that complications that arose post-discharge were often preventable based on appropriate discharge education during the initial hospitalization.⁵

Pharmacists should also become keenly aware of other medications that can put patients at risk for recurrence. Continuous use of PPIs has been independently associated with a 50% increased risk for CDI recurrence in a retrospective review. Surprisingly, re-exposure to antibiotics was associated with only a 30% increased risk.⁶

Table 2. Emphasis of Educational Opportunities During ToC

In the end, pharmacists play a critical role in the transition of care for patients with CDI. Overall management should focus on educating the patient and optimizing the currently available drug and other therapies. In the meanwhile, all practitioners involved in the patient’s care have a responsibility of ensuring proper management and prevention of recurrence.

References

1. Feuerstadt P, Stong L, Dahdal DN et al. Healthcare resource utilization and direct medical costs associated with index and recurrent Clostridioides difficile infection: a real-world data analysis. J Med Econ 2021 ,23:603-609.https://www.tandfonline.com/doi/full/10.1080/13696998.2020.1724117. Accessed April 26 2021.
2. ASHP-APhA. Medication management in Care Transitions. Best practices, 2013. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/quality-improvement/learn-about-quality-improvement-medication-management-care-transitions.ashx. Accessed April 26, 2021.
3. Howard, Keith A., "Preventing 30-Day Readmissions of Clostridium difficile Patients Utilizing Targeted Discharge Instructions" (2015). Doctor of Nursing Practice (DNP) Projects. 63.https://core.ac.uk/download/pdf/216980266.pdf . Accessed April 26, 2021.
4. Kristeller, J. Transition of Care: Pharmacist Help Needed. Hosp Pharm. 2014 Mar; 49(3): 215–216. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3971101/
5. Fernandez KK 2017 Telephone Follow-Up to Reduce the Readmission Rate in Gynecologic Oncology Surgery PatientsNursing Theses and Capstone Projects. 283.https://digitalcommons.gardner-webb.edu/cgi/viewcontent.cgi?article=1286&context=nursing_etd. Accessed April 26, 2021.
6. McDonald EG, Milligan J, Freenette C, Lee T. Continuous Proton Pump Inhibitor Therapy and the Associated Risk of Recurrent Clostridium difficile Infection. JAMA Intern Med. 2015 May;175(5):784-91. https://pubmed.ncbi.nlm.nih.gov/25730198/