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1 EDUCATIONAL SERIES: Navigating Infection Control and Antimicrobial Stewardship in Long-Term Care Webinar #4 Infection Control: Prevention New England Nursing Home Quality Care Collaborative Webinar Will Begin Shortly. Call-In Number: (888) Access Code:

2 Shira Doron, MD Associate Professor of Medicine Division of Geographic Medicine and Infectious Diseases Tufts Medical Center Boston, MA

3 Discuss the elements that are essential to an infection control policy Outline the key strategies for prevention of device associated infections Review the special steps required to prevent the spread of highly resistant bacteria

4 Infections were among the most common causes of harm; accounting for 26% of adverse events Events related to infection Infection events deemed preventable Transfers to hospital from infection event Type of Harm Adverse events (n=148) 39 (25.8%) 22 (59%) 34 (87.2%) Temporary (n=113) 20 (16.8%) 9 (45%) NA Hospitalizations from infections were estimated to cost ~83million dollars (the most expensive cause of harm) OIG report: Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries (OEI ), February

5 million HAIs 1 Leading cause of mortality, morbidity, resulting in 388,000 deaths 150, ,000 hospital admissions 26-50% due to infections $673 million-$2 billion for hospitalizations 2 Up to 70% of residents receive an antibiotic 4 UTI s most commonly treated infection (32%) 3 Up to 75% of antibiotics prescribed incorrectly 4 $ million on antimicrobial therapy % of all LTC residents have a urinary catheter 6 88% placed in LTC or non-acute care settings 5 99% of catheterized residents have asymptomatic bacteriuria within 30 days 7 5

6 Lack of resources <30% of nursing homes have full time IP staff Lack of expertise <10% of infection prevention coordinators receive formal training Communal living Must balance the needs of the resident to socialize and rehabilitate against benefits of isolation to prevent transmission Staff engagement and education High turnover Lots of part time personnel

7 Phased in Implementation Component Date of Implementation Phase 1 Infection Control Program 11/28/2016 Phase 2 Phase 3 Infection Control Facility Assessment and Antibiotic Stewardship 11/28/2017 Infection Control- Infection Control Preventionist 11/28/2019

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9 Review facility policies and procedures Modify or create new policies and procedures Identify staff who should be part of the review and development of policies and procedures Develop and implement staff training Creation of trained IP position Adhere to timeline for completion of new requirements

10 MDPH LTC Infection Control Guidelines C. diff, Pneumococcal disease, GI illness (including Norovirus), Herpes Zoster, Legionella, MDROs, Scabies, TB /epidemiology/providers/infection-control.html AHRQ quality-patient-safety/quality-resources/tools/cautiltc/modules/resources/guides/guide-infection-prevention.pdf CDC Infection Prevention Resources for Nursing Homes CAUTI, C. diff, MRSA, Norovirus, Influenza, CRE AMDA/CDC/SHEA 2018 infection prevention in PA/LTC certificate course 918af5db46b ac0.pdf

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13 Have written IC policies and procedures based on evidence based national guidelines Mandatory training for staff Annual risk assessment: use it to drive initiatives Written surveillance plan should be based on risk assessment One or more individuals with specialized training (could be certification or a course), at least part time The IP should report regularly to the quality assessment and assurance (QAA) committee RCAs being used to evaluate adverse events related to breaches in infection prevention System for early detection and management of symptomatic infected residents, on admission (review transfer record, thorough intake assessment) and thereafter (notification by lab to IP)

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20 I don t want to transmit MRSA between residents but do I want to transmit MSSA? Why do I have to put a resident on contact precautions for a VRE bloodstream infection? If we only isolate the residents we KNOW have an MDRO, and MDROs (especially MRSA) are so common, aren t we missing more residents than we are isolating? Why am I swabbing noses for MRSA when that s not where the infection is? The guidelines have not been updated since 2007

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22 There is currently no definitive data to support the decision about when to discontinue contact precautions; however, the resident s risk of transmission to others (e.g., overall health, dependence on healthcare, and device use) can be considered. In most cases, the absence of active wound drainage, diarrhea and copious contaminated secretions greatly reduces the risk presented by an infected or colonized individual. Note: this does not apply to CREs

23 Write a policy that makes logical sense to you and make sure your staff are following it Isolate organisms that have the potential to be of clinical and epidemiologic significance Example: if the MRSA rate in your facility is >80%, precautions may not be worth the resources Consider focusing on the patient rather than the organism Use gowns and gloves for patients with weeping wounds, productive coughs, and who are incontinent of stool rather than those colonized by MDROs Make sure you re really nailing standard precautions

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27 Cause infections with high mortality rates (up to 50%) Carry genes with high levels of resistance to many antimicrobials, limiting treatment options Resistance can be transmitted between organisms or between patients Spread rapidly and therefore require the most rigorous infection control measures Have spread throughout many areas of the U.S. and can spread more widely Enterobacteriaceae can become resistant to carbapenems by: The transmission of resistance genes from one bacterium to another The production of enzymes that inactivate carbapenems (i.e., carbapenemases)

28 Person to person via contact with infected or colonized individuals via hands of healthcare personnel via contaminated medical equipment Contact with stool or wounds Contact with contaminated environmental surfaces (e.g., bed rails) Can cause: Bloodstream infections Ventilator-associated pneumonia Surgical site infections Intra-abdominal abscesses Urinary tract infections Asymptomatic colonization

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31 -Responsible for the worldwide spread of carbapenem resistance -Easily transmissible, even transmitting the resistance mechanism to other bacteria Notify MDPH upon patient transfer Notify administration Go back 12 months and review records for other potential cases HH campaign and monitoring Educate staff, residents and affected patients about CP-CRE Enhance disinfection and implement a monitoring system Audit equipment disinfection Initiate screening cultures of high-risk contacts Cohort nursing staff (if more than one case, cohort on same wing) Place patient in a private room In the case of a cluster, initiate active screening cultures Call MDPH Epidemiology 24/7: for guidance!

32 Residents should not be discouraged from participating in meals and activities, provided their source of CRE is covered and contained Enlist the help of MDPH to discuss details Discontinue when three negative rectal or peri-rectal cultures At least 3 months from last positive culture AND At least 3 months after last course antibiotics AND Each culture at least 1 week apart Also culture the original site of infection if still present (e.g. open wound)

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34 What is the most important thing you can do to prevent infection in healthcare?

35 CMS requires a hand hygiene policy Should outline practices for staff, residents, and visitors Training and competency upon hire and annually Hand hygiene must be performed Before and after contact with the resident Before performing an aseptic task (giving an IV, doing HD or PD) After contact with blood, body fluids, visibly contaminated surfaces or after contact with objects in the resident s room After removing personal protective equipment (e.g., gloves, gown, facemask) After using the restroom Before meals When passing meds

36 y_how_and_when_brochure.pdf Enrollment-and- Certification/GuidanceforLawsAndRegulations/Dow nloads/appendix-pp-state-operations-manual.pdf

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38 RCT of 26 NHs, half received HH bundle aimed at residents, visitors, staff, and outside care providers Bundle: access to alcohol based sanitizer (both pocket-sized and dispensers), campaign posters and events, facilityspecific guidelines, staff e-learning education, and consistent technique training Tenime L, Cohen N, Ait-Bouziad K, et al. AJIC. 2018; 46:

39 Soap and Water Best when hands are soiled Infrastructure requirements (access to sink) Limited by poor technique Especially for residents with strength and mobility limitations Waterless Various products Gel, foam, wipes Faster, more accessible When in doubt, install MORE dispensers (keep fire codes in mind) Less drying, because coformulated with moisturizer

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41 Cure, L and Van Enk, R. American Journal of Infection Control 43 (2015)

42 CDC guidelines (last updated 2002): None of the agents (including alcohols, chlorhexidine, hexachlorophene, iodophors, PCMX, and triclosan) used in antiseptic handwash or antiseptic hand-rub preparations are reliably sporicidal against Clostridium spp. or Bacillus spp. Washing hands with non-antimicrobial or antimicrobial soap and water may help to physically remove spores from the surface of contaminated hands. HCWs should be encouraged to wear gloves when caring for patients with C. difficile associated diarrhea. After gloves are removed, hands should be washed with a nonantimicrobial or an antimicrobial soap and water or disinfected with an alcohol-based hand rub. During outbreaks of C. difficilerelated infections, washing hands with a non-antimicrobial or antimicrobial soap and water after removing gloves is prudent.

43 Natural nail tips should be kept to ¼ inch in length Nail polish must not be chipped Artificial nails should not be worn

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49 Staff: Provide moisturizer or lotion-soap must be compatible with HH products (check with manufacturer) Monitor compliance Consider de-identifying and circulating data Create internal competition between units, job classes, etc. Engage nurses by their cause Every time you perform hand hygiene is an opportunity to demonstrate how much you care Residents Provision of alcohol-based sanitizer packets with meal trays Provide multiple modalities, visual and verbal reminders Loyland B, Wilmont S, Hessels AJ, Larson E. Nurs Res. 2016; 65(2): Grayson ML, Macesic N, Huang GK, et al. PLoS One. 2015; 10(10): e Rai H, Knighton S, Zabarsky TF, Donskey CJ. AJIC. 2017; 45: Knighton SC, McDowell C, Rai H, Higgins P, Donskey CJ. AJIC. 2017; 45: O Donnell M, Harris T, Horn T, et al. AJIC. 2015; 43(2):

50 Appropriate personnel: training and competency upon hire and annually Audit adherence and provide feedback Monitor and track personnel with access to controlled substances (talk about the infection risk associated with diversion) Rubber septums on vials disinfected with alcohol Multi-dose vials can be used for more than one resident unless they enter the care area You can t do a finger stick and have the insulin in the room ready to use

51 Appropriate personnel: training and competency upon hire and annually Appropriate personnel: training and competency validation annually Audit adherence and provide feedback If devices cannot be dedicated to one resident, must be cleaned between residents according to manufacturer instructions for use

52 Year State # infected Equipment implicated 2016 PA 2 Glucometer 2014 PA 8 Glucometer 2014 CA 7 Podiatry equipment 2012 VA 2 Fingerstick device 2011 VA 7 Fingerstick device 2011 CA 2 Glucometer Podiatry equipment 2010 CA 3 Glucometer 2010 NC 8 Fingerstick device Glucometer 2010 TX 24 Glucometer 2010 VA 14 Fingerstick device Glucometer 2010 VA 5 Fingerstick device

53 18 outbreaks occurred in long-term care facilities between 2008 and 2016, with at least 133 outbreak-associated cases of HBV and approximately 1,680 at- risk persons notified for screening 83% (15/18) of the outbreaks were associated with infection control breaks during assisted monitoring of blood glucose (AMBG)

54 Only properly trained individuals who demonstrate competency may access and maintain CL Document insertion date and indication HH before and after manipulating Dressing CD&I Dressing change aseptic technique Scrub the hub 15 seconds (alcohol, CHG, povidone iodine or iodophore) Regular assessment and documentation of need and prompt removal if not needed

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56 Provider documentation of rationale Acute retention Bladder outlet obstruction Neurogenic bladder Terminally ill for comfort Only properly trained individuals who demonstrate competency may insert UC Secure properly Document insertion date HH before manipulating, gloves worn Bag below bladder and off floor Tubing unobstructed and not kinked When emptied, don t let spigot touch collecting container Obtain samples from a port, not bag Regular assessment and documentation of need and prompt removal if not needed Remember, a resident cannot develop a catheter associated urinary tract infection if they do not have a catheter!

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58 Routine and terminal cleaning and disinfection of resident rooms and high touch surfaces in common areas Change or disinfect curtains between residents Cleaning/disinfection policies for shared equipment Reprocessing- make sure contractors and external consultants are following policies (podiatry, dental) Training and competency every 12 months Audit and feedback on quality of cleaning and disinfection Must have a chemical active against cdiff and norovirus Separation of clean and dirty: No clean items (eg linen carts, equipment) in dirty resident rooms or dirty utility rooms No dirty items (eg laundry, equipment) in clean utility rooms Keep in mind literacy and language barriers of cleaning staff and work with contracted service providers to properly assess competency Do they need instructions in other languages or visual cues to ensure protocols are followed?

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63 Policy on assessment and screening for TB Screen residents for TB on admission Require visitors to take precautions if they have respiratory symptoms Post respiratory etiquette signs Educate staff upon hire and annually on prevention of spread of respiratory pathogens

64 Early identification Protocol for notifying medical personnel when a resident develops diarrhea Policy that allows nurses to collect and order stool for C.diff Controversy!! Protocol for notifying medical personnel about positive test results

65 Rapid containment Policy allowing nurses to implement isolation precautions when a resident develops diarrhea Visual tool to communicate that contact isolation is in place Adequate supplies of gowns and gloves, appropriately placed Dedicated equipment for residents with CDI Policy to provide separate toilets or commodes for residents with CDI who are sharing a room

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67 Discontinue when no diarrhea for 72 hours Resident care items should not be shared Do not under any circumstances repeat the C.diff test (will be positive indefinitely) Restrict movement while symptomatic, then allow resident to participate in group activities Make sure hands and clothes are clean and body substances contained

68 A single patient room is preferred for patients who require Contact Precautions. For CDI: If possible, residents should be assigned to a private room with their own bathroom. If a private room is not available, residents with CDI/MDRO should be cohorted with other residents with CDI/MDRO. If multi-resident rooms are used, > 3 feet spatial separation is advised to reduce the opportunities for inadvertent sharing of items between the infected/colonized resident and other residents. Decisions regarding resident placement should be made on a case-by- case basis, balancing infection risks for other residents in the room, the presence of risk factors that increase the likelihood of transmission or acquisition, and the potential adverse psychological impact on the infected or colonized resident.

69 C.diff: /documents/ listk_.pdf Norovirus: /documents/ listg_.pdf

70 Also known as kill time or dwell time Amount of time a product needs to remain on a surface (wet) in order to be effective against the microorganisms on its label May be different for different organisms (e.g. 4 minute contact time for the usual organisms but for C.diff 10 minutes) Longer contact times may require multiple applications Consider the possibility that contact times greater than 4 minutes may be unrealistic

71 UV light (7 products on the market) Hydrogen peroxide vapor Electrostatic sprayers

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75 Hand hygiene Point of care device cleaning Shared equipment cleaning Contracted housekeepers Contracted providers (podiatry, ophthalmology, dental, wound specialists) who bring equipment

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77 Coming in Spring, 2019! Free of charge Will meet Phase 3 requirements for IP training Available on demand Will take hours Certificate provided upon completion

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79 MARK YOUR CALENDARS! May 8 th Jun 12 th Jul 10 th Aug 14 th Sep 11 th WEBINAR: Approach to the Patient with Suspected UTI WEBINAR: Infection Control: Management (Case Scenarios) WEBINAR: Antibiotic Selection, De-Escalation, and Duration WEBINAR: How to Get an A on Your Report Card: Prevention and Management of C. difficile and Other Healthcare Associated Infections WEBINAR: Measure Your Success: Monitoring and Tracking Data 84

80 New England Nursing Homes Commitment to Quality Improvement Take a photo of your badge displayed in your front entrance (bonus points if staff are included), post it to social media using the hashtag #WeCommit2Quality, and tag the New England QIN-QIO on any of the following: England QIN-QIO Facilities who use this hashtag will have a chance to be featured in New England QIN- QIO social media postings, newsletters and programs.

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82 New England Nursing Home Quality Care Collaborative Quality Awards Program Blue ribbons will be awarded to Collaborative participants who: Actively participate in the New England Nursing Home Quality Care Collaborative (ex: attending webinars and other learning events related to your quality goals) Implement performance improvement projects and best practices to help improve performance and health care outcomes and share as a success story to the New England QIN-QIO Gold ribbons will be awarded to Collaborative participants who: Achieved a composite score of 6.0 or below by September 2018 Earned and maintained a percentage at or below the state average for the long-stay antipsychotic medication quality measure by September 2018 Met criteria outlined for the blue ribbon requirements

83 QIN-QIO State Leads Connecticut Florence Johnson Maine Danielle Watford Massachusetts Sarah Dereniuk-Dudley New Hampshire Pam Heckman Rhode Island Nelia Odom Vermont Gail Harbour This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSMAC