WEBINAR: Infection Control Surveillance and Monitoring

Transcription

1 WEBINAR: Infection Control Surveillance and Monitoring January 11:00 am - 12:00 pm >> Good morning and thank you for joining the New England Nursing Home Quality Care Collaborative. My name is Sarah Dudley with the New England's -- and the webinar today is the Infection Control: Surveillance and Monitoring Webinar. This is the first of nine webinars in the Navigating Infection Control and Antimicrobial Stewardship in Long-Term Care Educational Series. This educational series is brought to you in partnership with the Massachusetts Department of Public Health and experts from Tufts Medical Center. Before we begin today s program, I have a few housekeeping items to review. This webinar will be recorded and the presentation will be available within the next few business days. The phone lines will be on mute and we asked that you do not put your phone lines on hold. If you have a question at any point throughout the presentation, please enter it in the chat panel to the right of your screen. Please make sure to send your comments to all participants. Nayara, from the QIN-QIO team along with myself, will be responding to any questions and comments in chat. Any questions for the speakers will be held and will be brought back with the speakers when we open up the line for questions and comments at the end of the presentation. >> If you find that the presentation is a little cut off, please use the plus or minus icon in the top right of the presentation window to adjust your screen accordingly. Next slide, please. >> To introduce our first speaker, and to welcome you all to this series I will turn it off to Melissa Cumming from the Bureau of Infectious Diseases and Laboratory Sciences at the Massachusetts Department of Public Health. Melissa.. >> Thank you, Sarah. Thank you so much for joining us today. We think that you will find the information presented very helpful. Without further ado, I d like to introduce Dr. Shira Doron from Tufts Medical Center. >> Dr. Doron is a physician in the division of Infectious Diseases at Tufts and she has been the physician head of the antimicrobial stewardship program there since 2005 and is also the associate hospital epidemiologist. She also leads a team at Tufts that is available to provide on-site consultation to longterm care facilities working to implement their own antimicrobial stewardship program. With that why don't you take it away? >> Thank you. We ve done some of these webinars before focusing on antimicrobial stewardship but this is the first one that we are doing on infection control. Obviously, in the fight against multidrug resistant organisms and antibiotic resistance, infection control really goes hand-in-hand with my antimicrobial stewardship. So this first webinar is focused on surveillance and monitoring. Before we

2 begin, Emilee and Jennifer, please open the poll. We will ask everybody to respond to the polling question: How confident are you that the infection control policy and practices in your facility are adequate to protect your residents from healthcare-acquired infections? >> Go ahead and enter response. Be sure to hit the submit button so that your response can be tallied with everybody else s. We have 45 seconds to answer and we will review the answers. Really, what we are trying to do is establish whether these webinars are useful to you. We need to figure out what your needs are for future webinars. The more feedback we get from you in general, the better. >> It seems we are just waiting for the tally of responses. I do not see the same screen as you do. I am going to ask this out. >>Not surprisingly, we have the majority of respondents feeling somewhat confident but not completely confident. Luckily, we only have one facility that feels a complete lack of confidence. That's why we are here, and the learning objectives for today are to talk about creating your institutional surveillance plan. That is really understanding how to perform a facility risk assessment to guide your plan. What s important to your facility? What makes sense for your facility? And then understand why case definitions are important and how to apply them. We re going to talk about the McGeer criteria and the National Health Safety Network, or NHSN criteria. We re then going to go into what is the NHSN and how it can help you. And what infection control basics should be addressed in your surveillance plan? That means, what kind of data one should collect and the use of data collection tools. >>If you are confused about what the verb is for the noun surveillance, you are not alone. Some people like to say surveil or survey. I don't know the answer to that question. But what elements should go into my surveillance plan? I can help you with that. The bottom line is your surveillance plan should be based on your risk assessment. It should be revised at least annually. >>A risk assessment is where you evaluate risk. You take input from infection prevention from your medical staff, nursing staff and facility and leadership, and you determine the priorities for your institution based on the identified risks for acquiring and transmitting infections, in this case. Then you develop goals to minimize infection transmission. You also develop and implement and monitor measures to achieve your specific goals. We will go through all of those steps. We really like the University of North Carolina risk assessment tool. I am sharing my screen here with you, so I will leave the PowerPoint presentation and I will open this Excel spreadsheet. You will receive an tomorrow following up on this webinar. The is going to contain the link to the UNC risk assessment tool. There are others out there online. I like this one because it's simple. The way it works is that you've got your events down the left-hand column. Across the top, the probability of one of these events occurring, high, medium, low, or none. So, risk level of failure If there is a failure, will it be life-threatening? Permanent harm, temporary harm, or no harm? The potential change in care for that resident or patient so, will treatment be needed? High, medium, low or none. Are there current processes? How prepared are you right now? All of these numbers will be added up. We've added a formula here for what the spreadsheet has so that it ll automatically add it up for you. A score level of 8 or more is considered the highest priority and should definitely be a part of your surveillance plan. So these types

3 of events are included here and you can certainly add your own for your residence risk of TB, facilityassociated infections, symptomatic UTI, influenza, pneumonia, lower respiratory tract infections, cellulitis, things like that. Antimicrobial stewardship related events. Lack of leadership support. Inadequate written policies. Exposure-related events so things like assessable hand sanitizer and hand hygiene compliance are here. Healthcare personnel related events so influenza, immunization, resident and family related events, environment, medical supplies. So let s take this one as an example. Inadequate cleaning and disinfection of resident rooms. Let's say you've done some assessment. You have determined that there is an issue in your facility with cleaning of resident rooms. They are not necessarily being done on the daily basis. People are finding that the rooms don't look so clean. You would enter into this section: What is the probability of an event related to an inadequate room cleaning? What is the probability that you would have an inadequately cleaned room? So let s say that this has been brought to your attention and you think it s a medium probability issue. It is happening with some kind of regular frequency. >>What will happen to the resident as a result of that? Well, if a room isn't clean, particularly terminally clean, that resident could acquire C. diff, MRSA, VRE and that level of harm let s s ay its somewhere between temporary and permanent, let s say permanent because once you ve acquired VRE or C. diff that can stay with you for a lifetime well, that has the potential to change care. If the patient has C. diff, they are going to need care. They may need antibiotics. They may need hospitalization. In severe cases, they may need a colectomy, so let s put that as a medium. But are we prepared? Are we dealing with this? Do we have processes in place? Let s that even though you ve identified a problem, you've already implemented some kind of audit of room cleaning. Perhaps, a housekeeping supervisor who goes in and looks at rooms after they have been cleaned to go through a checklist for high touch points, for example, so you've got some kind of fair processes in place. That gives you a score of 8 here. That is just summing up the numbers for risk level. Because it is a score of 8 or higher, environmental cleaning would make it to your facility s surveillance plan. >> We re trying to go back to our PowerPoint presentation. What are some other things outside of your risk assessment tools that will be in your surveillance plan? Well, you might want to use published, evidence-based surveillance criteria for things like your healthcare facility s onset infections, and you re going to need definitions. You will want to apply those definitions and criteria in the same way every time for every patient. So there are criteria available through the NHSN, and there are criteria specifically for long-term care, and there are criteria from McGeer which I m going to show you in a moment. You're going to want to use data collection tools, and I ll show you some tools at the end of this presentation that you can use. And you are going to want to plan to update your quality assessment assurance committee at least quarterly with the data that you collect. You also want to have a plan for follow-up activity and response to that surveillance data. As you are doing surveillance, if you find an uptick or an outbreak, of say C. diff, VRE or MRSA, etc., you will want to have a reporting plan as part of your risk assessment and surveillance plan. You will want an annual summary of all of your surveillance data. >> Nemalle Stone is the CDC officer who heads the project to improve infection control in long-term care. She wrote this paper in 2012, Surveillance Definitions of Infections in Long-Term Care Facilities,

4 she revisited the McGeer Criteria which has been around for quite a while and developed the CDC criteria and we re going to send you a link to this paper in tomorrow's . In her paper, she describes points to consider. She divides up surveillance into 3 categories: infections that should be included, infections that could be considered, and infections for which other accepted definitions should be applied. You might apply them only to specific at-risk residents. For example, if you skip to the bottom of this table, if you have a facility where residents have central lines or if you do vent cleaning at your facility, you would use NHSN criteria that acute care hospitals use to do surveillance for those types of infections. Otherwise, you re going to look at points A and B and use long-term care specific criteria or you might develop your own. So, infections that should be included are those that have evidence of transmissibility in a healthcare setting, those that have processes available to prevent acquisition of infection, and those with significant morbidity or mortality. >> That would include things like viral respiratory tract infections, viral gastroenteritis, viral conjunctivitis, which are associated with outbreak, pneumonia, urinary tract infection, G.I. infections including C. diff, skin infections those are preventable, but they are associated with hospitalization and functional decline. So they are important. And then any specific pathogens that cause serious outbreaks. So invasive group A even one laboratory confirmed case she prompt further investigation. Acute viral hepatitis norovirus, scabies, influenza those should all be part of the surveillance program. >>Now, infections that could be considered are those with limited transmissibility or limited preventability. So ear and sinus infections are generally not so much of an issue because they happen and they aren t really due to anything that you are doing within your facility. Whereas fungal, oral, or skin infections might be due to something that is going on in your facility. It could just be related to overuse of antibiotics. It is something to take note of if you think you re having a problem. As I said, there are sort of two main sources for surveillance definitions. You can adapt these for your own use. So there is NHSN and there is McGeer. Now McGeer originally published a paper in 1991 and it was strictly based on expert opinion and only applicable to elderly, institutionalized adults. These criteria were updated in 2012 to be in line with more recent diagnostic technology and be a little bit more similar to existing NHSN definitions. And again, you will have access to these slides later, so you don't have to be frantically writing down these URLs. >>McGeer has a bunch of criteria. Constitutional criteria for infections is one, respiratory infections, so there are criteria here for the common cold, laryngitis, pneumonia, bronchitis tracheal bronchitis. I think the most important and the one used by most facilities is the McGeer criteria for UTI. This is complicated: this is the one for UTI without an indwelling catheter and this is the one for UTI with indwelling catheter. And we are going to spend a lot more time in a later webinar discussing how to assess the patient for the presence of a UTI and how to determine whether a patient should be tested for UTI and treated for UTI. This definition really, is for surveillance, to see if you have a UTI problem. Cellulitis, soft tissue, wound infection, as I mentioned, probably not a part of most surveillance plans. Scabies definition here so that if you want to be monitoring for scabies, you can be using the same criteria for every time you are assessing a resident. Oral candidiasis, fungal skin infections, herpes simplex or herpes zoster conjunctivitis all of those fit under the available McGeer criteria. As well as

5 gastroenteritis, including specifically, norovirus gastroenteritis, and there is a McGeer criteria for C. diff infections. >> The NHSN has standardized surveillance definitions for long-term care. This is the resource here. There are definitions for C. diff, MRSA, UTI and some prevention processes. What's really important and I want to make sure that everyone takes this away is that neither the McGeer criteria nor the NHSN definitions of infections are meant to be used as criteria for treatment of suspected infection with antibiotics. They are intended for standardized surveillance purposes only. So you can use these criteria to make sure that if you are counting the number of infections that you have in a given time point, you re counting the same way each time. But you should not in any way shape or form take these criteria to mean that they should be clinically or used for testing or treatment. Again, we will talk about testing and treatment in the other webinars and how they relate to antimicrobial stewardship and antibiotic use. >>The NHSN is part of the CDC it is their healthcare-associated infection tracking system. The NHSN collects and feeds back data to facilities, states, regions, and nationwide. Their goal is to identify infection prevention, planning, to benchmark progress of infection prevention efforts and to drive progress towards the elimination of healthcare-associated infections. >> At the present time, NHSN reporting is a voluntary, pilot project for long-term care. Now, in acute care and hospital settings where I am, much of the surveillance plan is going to be really dictated by NHSN. We have many requirements where we are required to report to NHSN on a variety infections and other things. But for long-term care, there are no current requirements. So your surveillance plan isn t going to be dictated by NHSN requirements. But it is expected that NHSN reporting is going to become mandatory in the not-too-distant future. Probably the first element will be C. difficile events. >> We have about 90 long-term facilities enrolled in NHSN and reporting on C. difficile. And there are community onsets and long-term care onsets LabID events. So that means that a lab diagnosis, a case of C. diff, if the specimen is collected in less than three days after the date of admission to the facility, it is called a community onset LabID event and a long-term care facility onset if the specimen is collected more than 3 calendar days after admission, which is the one of more concern. >> The Department of Public Health in Massachusetts will be doing external validation of the data on 10 nursing homes to see how they are doing at entering or uploading this data, and whether its accurate. We strongly encourage facilities that are not currently using NHSN to do so. We do provide support to assist you and there are benefits to you in reporting. Some of the future quality measures after C. diff MRSA rates, urinary tract infection rates, HPC influenza vaccination rates, hand hygiene compliance, gown and glove compliance, HPC blood/body fluid exposure these are some of the ideas being kicked around in the CDC right now. What else could I survey or put in my surveillance plan? We talked about outcome measures. Did the resident develop an infection? You can also put process measures in your surveillance plan. That could include things like compliance with standard precautions. So, your hand hygiene compliance rate could be part of your surveillance plan your proper use of protective equipment, your safe injection practices. Hand hygiene basics could include things like alcohol-based

6 hand rub accessibility. Is it in an accessible location? That could be monitored on some regular basis. Within hand hygiene, are our providers washing when their hands are visibly soiled, and otherwise either washing or using alcohol-based hand wipes. Are our providers washing even when gloves are used? So you can have some sub-categories that you might want to monitor. Within personal protective equipment basics, you can ensure that gloves are being used whenever blood or body fluids are being contacted, mucus membranes, non-impact skin, that providers are working from clean to dirty or that they are changing gloves, that gowns are being used for uncontained secretions and that facemasks are being used within 3 feet if the patient has an acute illness. >> You could look at things like the use of dedicated disposable equipment or that disinfection is being done. Particularly whether the instructions for use are being followed. Also, facilities will monitor their point-of-care items like the glucometer. We talked about cleaning and disinfecting. That is something that could be audited and monitored and go in your surveillance plan and your reporting plan. Influenza and pneumococcal vaccinations is a requirement for residents by CMS but you could monitor the vaccination of staff and DPH in MA does require an annual data submission by survey but it is currently not an NHSN requirement. >> Now, you are required to report reportable diseases. We know that compliance isn't always 100% with that and that is one thing you could monitor, including outbreaks such as influenza, norovirus and also movement of patients with certain MDROs. >> Communication is a really big issue between acute care and other providers. We will talk a lot about communication as a stewardship issue. Without proper communication about pending tests, and rationale for antibiotics, it is hard to make good choices about antibiotics. So, doing some kind of surveillance and monitoring of your communication practices could be really be effective in improving care. >>You could monitor your employee health policy plans are your employees really staying home when they are sick? >> There are some really helpful resources for infection control, the MDPH LTC Infection Control Guidelines, where there are resources for C. diff, Pneumococcal disease, GI illness including norovirus, Herpes Zoster, Legionella, MDROs, Scabies and TB. And the CDC Infection Prevention Resources for Nursing Homes where they have resources for CAUTI, C. diff, MRSA, Norovirus, Influenza, and CRE. >> This website here, which is has infection control assessment tools for acute and long-term care patient settings and I want to highlight for long-term care resource here. These data collections tools are quite a few and you can you can use them or adapt them for monitoring in your facility as part of your surveillance plan. Here is a sample form for point-of-care testing and observation. This is something you might use for glucometers. That tool includes hand hygiene list reforms gloves, single-use lancet, and whether the testing meter was dedicated to the resident or cleaned and disinfected before the next resident. Here is a tool for hand hygiene monitoring and contact precautions for observations, room entry or room exit, or an after-resident contact, glove use, hand hygiene, gown use. Its all in this tool right here. Here is a tool for indwelling urinary catheter maintenance observations.

7 >> Those of you who have central venous catheters in your facilities, here is a central venous catheter observation tool. It would include PCC lines. Is the indication appropriate? Is the maintenance performed regularly? Are they clean, dry, checked, and with a date on it? Is hand hygiene being performed? Is the hub being scrubbed? Here is a wound dressing change observation tool. >> So there are some benefits to you reporting to NHSN. We find this information really useful in acute care. Here is a sample of an NHSN report that we got back and this is from our hospital on C. diff. It allowed us to benchmark ourselves against other hospitals. Currently, when you re calculating your facility rates for certain hospital associated conditions or infections, you can monitor yourself over time. That is useful. The most useful utility of monitoring rates is really to understand where you have a problem compared to other facilities like yourself. >> Here is our report. We were given a standardized infection ratio. A standardized infection ratio is a calculated as a factor of the number of expected infections for your facility. Now, some risk adjustment goes into that, so we are a tertiary care referral center with a certain number of beds, we have a certain level of complexity care of patients including transplants. So we had an expected number of C. diff. as 63.5 but our actual number was 70 cases. >> So our SIR, after adjusting for all of that risk was 1.196, and what you re aiming for is an SIR of 1 or less. One means that your infection ratio I right about where it should be. >> That's to be compared with your SIR goal, and the default goal from the services is a 30% improvement. Now, NHSN will go on further to issue a task report and they do these quarterly. They will tell you what your hospital or facility s secret code is. Then they ll rank the hospitals according to how well they are doing on this type of infection and the top hospital there number 1 would be the worst. They will tell you what the cumulative attributable difference is, the number of infections needed to avoid in the quarter to meet your goal. Then they will compare your SIR or your number of infections to your predicted number of infections or your SIR to 1, using statistical analysis. So let s say that your SIR is 1.16, the goal is 1, is that statistically significantly greater than 1 or is it sort of within the range of statistics. So in this case there are some hospitals that have statistically significantly high C. diff rates, some that, although they may have looked lower or higher than one, were in the typical range of actually being the same. >>So, we re going to follow up now that I ve given you some information. Emily or Jennifer, you can go ahead and open the poll. Please submit your responses and hit submit. After participating in this webinar, you can check all that apply. >> [ Event is being polled ] Options: I feel better prepared to develop my facility surveillance plan for infection control, I understand the infection control basics that should be addressed in my facility surveillance plan, I want to learn more about using the National Healthcare Safety Network to track CDI in my facility. >> Please do check all that apply. Don't feel that you have to select one over the other. Then hit submit when you are done. I hope that anyone not using NHSN will be interested because it is very useful

8 information. All of the results are in. We will wait for the polling results. After we take a look that we will move onto the Q&A session. I think I will exit out. Here are the results. Let's take a look at them. I'm glad to see that some people are feeling better prepared and understanding the implications here, and people interested in learning more about NHSN. >> I'm going to exit out of the PowerPoint now so that I might be able to see if I can see the chat. I can't see the chat. So, as we do Q&A, if there are questions in the chat, could somebody read them to me please? >> Shira, Nayara is monitoring chat so any questions in chat she ll read. Are you ready to open up the lines for questions? >> I sure am. >> If anybody who wants ask a question, please dial #6 to unmute your line. Also make sure that if you manually muted your line that you unmute your phone as well. Also, you can ask a question in chat as well. Let's see if anybody has joined the line first. >> [ Pause ] >> To ask a question, please a dial #6 and then unmute your line. There are currently no questions in the chat. >> I spoke to soon. Here is a question. Most of our companies do not use any NHSN standards yet. Are the standard surveillance rates that our center should be comparing the rates to? >> Shira: At this point, no. At this point, I think even if NHSN were to provide benchmark rates for feedback at the end of 2018, you would have to take that information with a grain of salt because its a voluntary program and one might suspect that the facilities with better rates are the ones that are submitting. I would suspect that we would get some national rates back in early But that doesn t necessarily mean that that number is something that you should be comparing to your facility rates. Once all the facilities are submitting on a mandatory basis then you will know what the national rates are to which you should be compared to your own. >> Other questions? >> Can we call you for personal help? >> Shira: So we have a few different options for resources for personal help. Someone will mention some of the upcoming calls that we have where you can call in with questions. In addition, my institution will provide contracted services to any facilities. We have a variety of resources between QIN- QIO, DPH, privately contracted services, and the upcoming calls where you can ask specific questions for your facilities that you might need help with. >> Okay, thank you.

9 >> If there aren't any other questions, you can turn it back over to whoever wants to go over these last slides. >>Shira, I was disconnected. So, I apologize if you asked anything from me and I didn t reply. We do have one more question from chat. It is from Shelby: When determining whether or an infection was developed in the facility vs in the hospital or communities, are there standardized criteria that are available? Generally, if a patient develops something over 48 hours after admission I deem it facilityacquired. >>Shira: Obviously, that distinction is relatively arbitrary. The longer someone has been in your facility before developing symptoms of that infection, the more likely it is that they developed it in your facility. The NHSN did decided to use a 3 day cut off for C. diff. Again, that is simply based on statistics and common knowledge that if the resident has been in your facility for more than 3 days, it's more likely that the infection developed there. But, that s not always true. In the past, internally, we used to actually use whether or not the patient had symptoms at the time of admission as part of the definition. With a new concept of lab ID, you really don't get to get out of that facility onset infection designation. If it just so happens that you got a stool specimen on day 4, but you know that the patient has had diarrhea since day zero or one, you no longer can get out of that infection being categorized as a facility onset. Really, hat may seem unfair, but in infection control we kind of say that you live by the sword and you die by the sword. You will get out of infections that you know occur in your facility by these rules as well. The more NHSN can make the definitions very clear-cut, they realized that it's better that way so that we know that every single time you are calling something C. diff, you are applying that definition exactly the same way. If you are doing internal surveillance and coming up with their own criteria, three days is a good cut off. Less than or equal to 3, you can call that community onset. Greater than 3 you can call that facility onset. It's arbitrary. You don't have to follow that if you don't want to. But, in the future, NHSN mandatory criteria, it's likely that they will use a three day cut off. >> We have another question in chat from Mary Jane. Do you recommend re-culture of MDROs? Would you consider that a resident colonized with care with room care placement? For example, not rooming that resident with a history of an MDRO with a resident with a history of a PCC. >>Shira: They probably meant CREs. So, re-culturing for MDROs. That is a tricky and complicated question and I think each facility has slightly different policies and procedures for clearing a resident from isolation precautions. There isn't great evidence for isolation precautions and clearing from isolation precaution. It is -- there are some facilities that go by whether the clinical side of infection has been resolved, other facilities will culture for colonization. I can't say that one approach versus another is correct. Now, when it comes to CREs, there are resources from, at least the Massachusetts DPH, to guide screening isolation and sending samples to the state, which will determine what type of CRE we are dealing with and therefore that will actually lead to a different approaches depending on what the type of CRE is. Certainly at this point in time, I would say that if the patient has a CRE, and for those of you not really familiar with CREs, they are sort of the biggest and baddest of the superbugs. They are resistant to the very last resort of antibiotics that we have. Those residents you would want to try to keep away from others. I m not sure if I would distinguish between PCC lines and not PCC lines, but I

10 would certainly suggest being in contact with your Department of Public Health if you have a patient or resident with a CRE in your facility to discuss the best approach. >> We do have one more question in chat: My facility has two co-medical directors who sometimes are not on the same page. Any suggestions on getting people on the same page? Sometimes trust in the clinical staff and information handoff to the MV has something to do with testing, treating, sending out? What are your thoughts? >> Shira: That's a really good question. As we have been doing these workshops and webinars, we hear a lot of the story quite a bit. We have nurses that are on board with the concept of stewardship and diagnostics stewardship and not over-testing. Then we have medical directors that are putting up barriers. Specifically, your situation is difficult because you have two medical directors. What we're trying to achieve here is a culture change culture of prioritizing and limiting antibiotic use, prioritizing infection control measures to limit the spread, and it sounds like you re up against a really difficult situation. There was a paper published very recently in the Journal of Clinical Infectious Diseases that talked about some pf the more successful approaches to antimicrobial stewardship and long-term care. In this situation, the more successful way to overcome that kind of barrier would be to bring in outside help. So the more you reach out to your Department of Public Health, the more you reach out to your affiliated acute care hospital with experts, or contract from the outside with experts to provide advice. That's the kind of thing that medical directors are likely to listen to. So, involving experts in whatever way you can. >> Alright, I am going to do one more question from chat. How far apart should cultures be obtained for MDROs? For example, MRSA and urine, after treatment is over we need two consecutive negative cultures to take the patient off precautions. How far apart should those cultures be obtained? >> It sounds like an easy question. But again, there isn t actually a hard and fast rule on that. So that is going to be up to individuals and facility policies. I think you will be shocked to know that we don't actually isolate for MSRA colonization here at Tufts Medical Center. So that just highlights and shows you that there isn't a hard and fast rule here. So what we would say in the case of MRSA is when a wound heals, that's all it takes to continue isolation. I know that there were times when one had to have three negative MRSA screens in each one having to be 72 hours apart or whatever it was. But it's never really been standardized by the CDC so there isn't a simple answer to that unfortunately. >> Thank you Shira. I'm going to move on with a few reminders. I also wanted to remind folks from the Massachusetts area to stay on after our final reminder. We want to make sure you mark your calendars with the upcoming webinars from this series. The series run through September with webinars each month. >> Next slide, please. Contact information for your QIN-QIO state leads is on this slide. I also included information for both Melissa and Shira within chat. We will also include that in the that goes out following the webinar. You should all receive that with helpful links to tools that were mentioned during today's webinar. That should go out tomorrow. Next slide please.

11 >> The New England QIN-QIO is still continuing to recruit members to join our Patient and Family Advisory Council. Please reach out to Stephanie Baker. Her contact information is on this slide if you re interested or somebody who is interested. Next slide. >> Also, to access education we did see some requests in chat about education for infection preventionists, if you join the Learning Center, that is learning4quality.org, you can join all you need is your facility s CCN to access several learning modules for nursing homes including a series on infection prevention. >> Next slide, please. >> Don't forget to connect with that New England QIN-QIO on social media. This is where you can learn about additional education or important upcoming events. At this point, I want to thank you all for joining. I would like to ask all of the folks from Massachusetts twos please stay on the line. >> Melissa, I will turn it back over to you. >> Thanks, Sarah. >> If we can just go to the next slide. This information is directed to all of our facilities in Massachusetts. I just wanted to say a few words about how we feel about the information that we will be presenting in the next nine months long educational program. This information is really, really important for our long term care facilities. We also recognize the commitment of time and energy that you are making to participate. We would like to let you know that we will be providing facility-specific recognition from the Department of Public Health for those that complete the program fully, that participate in all nine webinars. We are planning to provide at the end of every session a follow-up that will go out including references that were covered in the webinar so that if you maintain an infection control and stewardship binder in your facility or policy binder, if you download the materials that we send you after each presentation, you will in fact be putting together your own facility policy binder, so we hope that you ll find that useful. All the templates, guidelines and references will come to you in them . The last point I wanted to make is to remind you that by committing to participate in the program for nine months, we are going to ask facilities to submit once a month -- I think it makes the most sense on the first of the month to submit data for the entire month. So on February 1 of this year, we will ask you to submit antibiotic stewardship data for the month of January using a very simple Survey Monkey tool that we have created. Shira, if you want to pull that up, she will scroll through the tool just so you can get a sense of what we are asking. It's really pretty basic. We hope that it will not be too timeconsuming for you to participate in. The goal is to look at antibiotic start information before, during, and after the program to see if we are helping you to reduce those starts. So Shira, I will turn it over to you. >> You will be receiving the link to this Survey Monkey survey every month. You would open it up and enter your facility name and your name. As Melissa said, you'll be entering around the first of the month for the prior month. You will list the number of antibiotic starts by antibiotic for the month started. They have been listed here. You would pull a list of every antibiotic imaginable. List of brand names and the generic names. If you used antibiotic that has a brand or generic name, just pick one. You don't need to

12 report from the generic and the brand name. So for example, this month you had a great month you only had five patients started on antibiotics, you did Cipro 3 times, so you re going to find Cipro and put in a 3. You did Keflex 2 times so you ll put in a 2 and hit okay. We were really quite comprehensive with our list. We re also asking for you to enter the number of resident days, so that is your daily census each day added together, and that ll allow us to really turn this into benchmarking data. So what does your antibiotic use look like per resident day and we could potentially compare facilities and even take that back to you. We are asking for the total number of long-term and short-term stay residents in your facility so we can get a sense of what type of facility you are and similarly all of the services that you provide to get a sense of the type of facility and number of beds. >>So its pretty simple, it should only take you a few minutes to do. We really would appreciate your doing that; I feel like it would be very useful information for us to help you and for you to have. >>Great, so I think that concludes the Massachusetts-specific information we were hoping to cover so just to let you know that we do plan to recognize facilities that complete all 9 components and submit their data each month. We will be providing resources, links, contact information, you can contact us with any questions about submitting that data, or the webinar content. >>I think that is all from us Sarah. >>Thank you. I do have one quick question in chat, if you don t mind, it is from Mary: Does this list include IDPs for the yes, etc.? >>No; I think its just systemic antibiotics. >>Ok, great; that s it for questions in chat. I also included the link to enter the monthly antibiotic facility use in chat. Again, there will be an that goes out tomorrow with all the resources. Again, if anyone has any questions, there is contact information provided in chat. Thank you everyone for joining, have a great day.