Infection Prevention and Control Changes, Updates and Quality Results! Sue LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT Director of Education Pathway Health 1 Objectives 1.Describe the recent industry expectations for Infection Prevention and Control 2.Describe the clinical processes affected by the industry updates 3.Verbalize 3 leadership strategies for successful implementation of an Infection Prevention and Control Program 2 Industry Landscape Industry Landscape 3 1
Final Rule Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities www.https://federalregister.gov/d/2016-23503 4 Final Rule The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards; 5 Final Rule 2. Written standards, policies and procedures to include: A system of surveillance designed to identify possible communicable diseases or infections before they can spread When and Whom possible incidents of communicable disease or infections should be reported 6 2
Final Rule (Continued) Policies and Procedures: Standard and transmission-based precautions Type and duration of isolation The isolation should be least restrictive possible for the resident under the circumstances Circumstances when employees are prohibited to work with a communicable disease or infected skin lesions 7 Final Rule (Continued) Policies and Procedures: Hand Hygiene for all staff involved in direct resident contact Antibiotic Stewardship Program (Phase 2- November, 2017) Protocols Monitoring A system for recording incidents identified under the facility s IPCP and corrective 8 action taken Final Rule Influenza and pneumococcal immunizations: Policies and Procedures Prior to offering-must provide education to the resident or resident s representative on benefits and potential side effects Influenza: Offer between October 1-March 31 annually unless medically contraindicated or already immunized during time period The Resident or resident s representative has the opportunity to refuse 9 3
Final Rule (Continued) Influenza Immunization Documentation in the medical record must include: Education provided to resident/representative on benefits & potential side effects Administration of vaccine or if not received, the medical contraindication or refusal 10 Final Rule Pneumococcal Immunization: Each resident is offered a pneumococcal immunization unless medically contraindicated or already immunized The Resident or resident s representative has the opportunity to refuse Documentation in the medical record must include: Education provided to resident/representative on benefits & potential side effects Administration of vaccine or if not received, the medical contraindication or refusal 11 Final Rule Pneumococcal Immunization: Each resident is offered a pneumococcal immunization unless medically contraindicated or already immunized The Resident or resident s representative has the opportunity to refuse Documentation in the medical record must include: Education provided to resident/representative on benefits & potential side effects Administration of vaccine or if not received, the medical contraindication or refusal 12 4
Final rule Other updates to Infection Control Linens: Personnel must handle, store, process and transport linens so as to prevent the spread of infection Annual Review: The facility will conduct an annual review of it s IPCP and update the program as necessary 13 Requirements for the Infection Preventionist 14 Final Rule Infection Preventionist Facility must designate one or more individuals responsible for the IPCP (Infection Prevention and Control Program Must have primary professional training in nursing, Med tech, microbiology, epidemiology or related field Be qualified by education, training, experience or certification Work at least part-time in the facility Have completed specialized training in Infection Prevention and Control 15 5
Final Rule Infection Preventionist must participate/be a member of the facility s QAA Committee and report on the Infection Prevention and Control Program (IPCP) to the committee on a regular basis * Both the Infection Preventionist and the Infection Preventionist participation on QAA are Phase 3: November, 2019. 16 CMS Current F-Tags potentially associated with antibiotic stewardship F441: Infection Control F315: Urinary Incontinence (UTI s) F329: Unnecessary Medications F428: Drug Regimen Review 17 Industry Landscape Current Regulations for F441: State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Table of Contents (Rev. 168, 03-08-17) https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf 18 6
F441: Infection Prevention and Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf 19 F441 Infection Prevention and Control 483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf 20 F441: Infection Control (2) Written standards, policies, and procedures for the program System of surveillance When and whom to report possible incidents of communicable disease or infection Standard and transmission based precautions When and how isolation should be used Circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions form direct resident contact or with their food if it will transmit the disease Hand Hygiene procedures staff must follow with direct resident contact https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_pp _guidelines_ltcf.pdf 21 7
F441: Infection Control 3. An Antibiotic Stewardship Program (November 28, 2017) 4. A system for recording incidents identified under the Infection Prevention and Control Program and corrective Action Additional requirements: **Infection Preventionist requirements **Infection Preventionist participation on quality assessment and assurance committee https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.p df 22 Overview: F441 Infection Control Infections are a significant source of morbidity and mortality for nursing home residents Account for up to half of all nursing home resident transfers to hospitals Infections result in an estimated 150,000-200,000 admissions per year to the hospital at a cost of between $673 million to $2 billion annually CMS: State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf 23 Prevention is the Key!!! 24 8
CMS 3 Part AIM: Better Care Healthy People Healthy Communities Affordable Care 25 Readmission Measure and VBP http://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-conditions-readmissions- 26 Payer.pdf Report Report to the President on Combating Antibiotic Resistance (September 2014): http://www.whitehouse.gov/sites/default/files/microsites/ostp/pcast/pcast_ca rb_report_sept2014.pdf 27 9
Report - Key Points The beginning of the 20 th century, 9 our of every 1,000 women who gave birth died - 40% from Sepsis In some cities - up to 30% children died prior to their 1 st birthday 1 out of 9 people who contracted a serious skin infection died (even scrapes and insect bites!) 30% of people with pneumonia died 70% of people with meningitis died Etc., etc. 28 Report What happened in the 20 th century? Improvements in public health Vaccines Antibiotics **Deaths from infections declined **Millions of lives saved primarily due to antibiotics! 29 Report We are losing progress!!! Antibiotic Resistance is now occurring at an alarming rate and is outpacing the development of new countermeasures capable of thwarting infections in humans 30 10
Report National Action Plan for Combating Antibiotic- Resistant Bacteria (March 2015): https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_ combating_antibotic-resistant_bacteria.pdf 31 Report The Centers for Disease Control and Prevention (CDC) estimates that drugresistant bacteria cause two million illnesses and approximately 23,000 deaths each year in the United States alone 32 Report Resistance is due largely to extensive exposure of bacteria to antibiotics. One of the recommendations for LTC includes Stewardship programs by the end of 2017, CMS should have Federal regulations (Conditions of Participation) in place that will require LTC facilities to develop and implement robust antibiotic stewardship programs that adhere to best practices. 33 11
CDC Centers for Disease Control and Prevention 34 MDRO s 35 CDC - Centers for Disease Control and Prevention Still Current! http://www.cdc.gov/hicpac/pdf/mdro/mdroguideline2006.pdf 36 12
CDC These six bacteria are among the most deadly antibioticresistant bacteria, identified as urgent or serious threats by CDC : CRE (carbapenem-resistant Entrobacteriaceae) MRSA (Methicillin-resistant Staphylococcus aureus) ESBL-producing Enterobacteriaceae (extendedspectrum ß-lactamases VRE (vancomycin-resistant enterococci) Multi-Drug resistant pseudomonas Multi-Drug resistant Acinetobacter http://www.cdc.gov/vitalsigns/protect-patients/index.html 37 (CRE) Carbapenem-Resistant Enterobacteriaceae Often found in GI tract Can be resistant to all or most antibiotics limiting treatment options Colonization can cause infection if the organism gains entrance to areas such as lungs, bladder or bloodstream http://www.cdc.gov/hai/organisms/cre/cre-clinicianfaq.html CRE Toolkit (CDC): http://www.cdc.gov/hai/organisms/cre/index.html Some facilities might chose to not place some non CP-CRE that remain susceptible to other antimicrobials on Contact Precautions. All patients with CP-CRE should be placed on Contact Precautions. (CRE toolkit) 38 Balancing Act! Quality, Protection, Safe Care & Resident Need 39 13
CDC - Management of MDRO s in HC Settings Use of Contact Precautions: In LTCFs, consider the individual patient s clinical situation and prevalence or incidence of MDRO in the facility when deciding whether to implement or modify Contact Precautions in addition to Standard Precautions for a patient infected or colonized with a target MDRO. https://www.cdc.gov/hicpac/pdf/mdro/mdroguideline2006.pdf 40 CDC - Management of MDRO s in HC Settings Enhanced Infection Control Precautions In LTCFs, modify Contact Precautions to allow MDRO colonized/infected patients whose site of colonization or infection can be appropriately contained and who can observe good hand hygiene practices to enter common areas and participate in group activities https://www.cdc.gov/hicpac/pdf/mdro/mdroguideline2006.pdf 41 CRE Toolkit https://www.cdc.gov/hai/organisms/cre/cre-toolkit/ 42 14
CRE Toolkit - CDC CRE are Enterobacteriaceae that are nonsusceptible (i.e., intermediate or resistant) to a carbapenem Some CRE possess a carbapenemase (carbapenemase-producing CRE or CP-CRE) that directly breaks down carbapenems CP-CRE were first identified in the United States from an isolate collected in 1996 and have disseminated widely since that time. Much of the increase in CRE since 2000 has been due to the spread of CRE that produce the carbapenemase Klebsiella pneumoniae Carbapenemase (KPC) https://www.cdc.gov/hai/pdfs/cre/cre-guidance-508.pdf 43 CRE Toolkit - CDC Acute Care Hospitals and High-Acuity Post- Acute Care Settings Acute care hospitals, long-term acute care hospitals, and ventilator units of skilled nursing facilities should generally place patients who are colonized or infected with CRE on Contact Precautions. Some facilities might chose to not place some non CP- CRE that remain susceptible to other antimicrobials on Contact Precautions. All patients with CP-CRE should be placed on Contact Precautions. https://www.cdc.gov/hai/pdfs/cre/cre-guidance-508.pdf 44 CRE Toolkit - CDC Lower-acuity Post-acute Care Settings: The use of Contact Precautions is more challenging Guide by the potential risk based on functional and clinical status and type of care activity performed Ventilator dependent Incontinent Draining wounds that are uncontrolled, etc. For all other residents, the gowns and gloves should be based on the care provided and potential risk of exposure to fluids or secretions/contamination i.e. bathing, toileting or incontinence assistance, wound care, devices, etc. https://www.cdc.gov/hai/pdfs/cre/cre-guidance-508.pdf 45 15
CRE Toolkit - CDC Residents with CRE at lower risk for transmission do not need to be restricted from common gatherings in the facility (e.g., meals, group activities). https://www.cdc.gov/hai/pdfs/cre/cre-guidance-508.pdf 46 Clostridium Difficile-HUGE CONCERN!!! CDC has developed a Toolkit http://www.cdc.gov/hai/pdfs/toolkit s/cdi-primer-2-2016.pdf AHRQ: Agency for Healthcare Research and Quality: Diagnosis, Prevention and Treatment of C. difficile: Current State of the Evidence May 30, 2017 https://www.effectivehealthcare.a hrq.gov/search-for-guidesreviews-andreports/?pageaction=displayprod uct&productid=2476&utm_sourc e=ahrq&utm_medium=en5&utm_ term=&utm_content=5&utm_cam paign=ahrq_en5_23_2017 47 Still Current - CDC http://www.cdc.gov/hicpac/2007ip/2007isolationprecautions.html 48 16
Guideline for Isolation Precautions Residents who are colonized or infected with certain microorganisms are, in some cases, restricted to their room. However, because of the psychosocial risks associated with such restriction, it has been recommended that psychosocial needs be balanced with infection control needs in the LTCF setting https://www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf 49 Final Rule - F441 483.80(a)(2)(iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances https://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/2017Downloads/R168SOMA.pdf 50 KEY POINT! DOCUMENTATION Symptoms Diagnosis Lab confirmation/type of organism Hygiene of Resident Uncontrolled drainage Uncontrolled diarrhea Room placement information Physician recommendations Hospital Infection Preventionist recommendation Medical Director recommendations ***Tell the story of your decision-making! 51 17
Use of Antibiotics-CDC Are overused Are misused Reactions and Side Effects Can only work with infections = bacteria Resistance is growing Reactions and Side Effects 52 CDC http://www.cdc.gov/getsmart/week/downloads/antibiotics-arent-always-theanswer-for-parents.pdf http://www.cdc.gov/getsmart/healthcare/learn-fromothers/factsheets/nursing-homes.html 53 CDC http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html 54 18
CDC http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html 55 CDC Core Elements for Antibiotic Stewardship Leadership Commitment Accountability Drug Expertise Action Tracking Reporting Education http://www.cdc.gov/media/releases/2015/p0915-nursing-homeantibiotics.html 56 http://www.ahrq.gov/nhguide/index.html 57 19
Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities-AHRQ https://www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/cauti-ltc/index.html 58 Leadership Strategies 59 Leadership Strategies Ensure we have the Components of an Effective Infection Prevention and Control Program in Place! 60 20
Components - Infection Control Program Program Development and Oversight Policies and Procedures Infection Preventionist Surveillance CMS: State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf Documentation Monitoring Data Analysis Communicable Disease Reporting Education Antibiotic Review and Stewardship 24 Leadership Strategies Program Development and Oversight 62 Development and Oversight Program Development and Oversight: Personnel Facility program oversight should collaboratively include: Infection Preventionist Administrator Medical Director (or a designee) Director of Nursing Other staff as appropriate 63 21
Leadership Strategies Policies and Procedures Up to Date! Evidenced-based, Standards of Practice 64 Policy and Procedure Will need written standards, P&P s to include Surveillance Reporting Standard and transmission based precautions Isolation When to prohibit employees with communicable diseases or infected skin lesions may work Hand Hygiene 65 Leadership Strategies Infection Preventionist 66 22
Infection Preventionist Responsibilities may include: Surveillance, collecting, analyzing, and providing infection data and trends to nursing staff and healthcare practitioners; Mapping infections Consulting with staff on infection risk assessment, prevention, and control strategies with adequate documentation; Providing education and training; and Implementing evidence based infection control practices including those mandated by regulatory and licensing agencies. 67 Communicable disease reporting oversight Mapping Infections Make sure you are mapping your infections in the building! 68 Leadership Strategies A solid, ongoing Surveillance Process! 69 23
2 types of Surveillance Process Outcome 70 Process Surveillance PROCESS SURVEILLANCE: Identifies your process is the process consistent with policies and guidelines? Audit - (hand washing, environmental rounds) Do your policies work? 71 Examples of Process Surveillance Hand Hygiene Audits PPE Audits Cleaning and disinfecting reusable equipment Observation of compliance with transmission-based precautions Etc. 72 24
Outcome Surveillance Outcome Surveillance: Identifies and reports evidence of an infectious disease The outcome surveillance process: Data collection Documentation of data Analysis (comparing to criteria and definitions i.e. McGeer criteria) http://www.jstor.org/stable/10.1086/667743 Data Analysis 73 Leadership Strategies Comprehensive Documentation! 74 Documentation and Data Documentation Criteria for Infection and definitions ONGOING, real-time surveillance 75 25
Use of Tracking Tools Identification of all infections in the facility Detection of types of infections and location in the facility. (Use McGreer Criteria) Determination of prevalence of infections Determine trends Information will assist the facility in the development of an effective Action Plan 76 Leadership Strategies Ensure Adequate Monitoring! 77 Monitoring Monitoring for actual infections based on criteria Facility practice/process Infection risks Symptom monitoring 78 26
Monitoring for S/Sx Infection Are staff trained on criteria and signs and symptoms of infection? What is your assessment process for staff to identify even subtle changes? Are there systems for monitoring and reporting of s/sx of infection - even on off-hours and weekends? 79 Leadership Strategies A Solid System for Data Analysis 80 Data Collection Data is collected from: Communication with staff both verbal and written Daily rounds-24 hour report review Review of MD progress notes Lab/X-ray results Treatment records New antibiotics? Nurse notes Information from hospital transfers 81 27
Data Analysis Current versus past infection control surveillance data Review and comparison of the reported incidence of infections including type and location (Map infections!) Reviewing and addressing data with objective data and identified plan quarterly for Quality Assurance Committee 82 Infection Rates Calculated monthly, quarterly, & annuallyfacility will develop a process for review and reporting Health facility acquired infections (HAIs) will be the infections calculated Recommend: Calculate infections per 1000 resident days A report form utilizing facility specific information can be utilized - there are multiple computer programs available to develop graphs for reporting and education 83 Leadership Strategies Communicable Disease Reporting 84 28
Communicable Disease Reporting The facility will want to have a Policy and Procedure that complies with all state requirements for the reporting of communicable disease The Infection Preventionist or designee will be responsible to report in accordance with Law Will need to report according to State Requirements 85 Florida Communicable Disease Reporting http://www.floridahealth.gov/diseases-and-conditions/disease-reportingand-management/ 86 Leadership Strategies Accessing Resources and Best Practices 87 29
References, Resources and Best Practices CDC: http://www.cdc.gov/ CDC - Nursing Homes and Assisted Living: Staff information Resident information Prevention Tools o i.e. Influenza Toolkit o Norovirum Toolkit o MRSA Toolkit, CRE Toolkit, etc. Health Department Resources http://www.cdc.gov/longtermcare/prevention/index.html 88 References and Resources CDC: http://www.cdc.gov/hicpac/2007ip/2007isolation Precautions.html http://www.cdc.gov/nhsn/ltc/index.html http://www.cdc.gov/hicpac/norovirus/002_norovi rus-toc.html http://www.cdc.gov/hai/organisms/cdiff/cdiff_se ttings.html 89 References and Resources APIC (Association for Professionals in Infection Control and Epidemiology): http://www.apic.org/ State Operations Manual, Appendix PP (F441): http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap _pp_guidelines_ltcf.pdf Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities Final Rule: https://s3.amazonaws.com/publicinspection.federalregister.gov/2016-23503.pdf 90 30
Important Resources Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria (SHEA/CDC Position Paper): http://www.jstor.org/stable/10.1086/667743 91 Resources Joint Commission (The Infection Prevention and HAI Portal) http://www.jointcommission.org/hai.aspx 92 Leadership Strategies Follow up and Oversight 93 31
IDT Involvement Infection Prevention and Control is NOT just a nursing department program! ALL staff need to be involved in training, implementation, oversight and compliance of infection prevention and control policies and procedures 94 Surveillance Oversight Review Process Surveillance Audits Hand Hygiene, Dressing Changes audits How are results handled? Review 24 hour Reports for residents with signs/symptoms of infections Are the Policies and Procedures followed? Review Lab reports-antibiotic consistent with results from C&S report? Check the infection mapping at least weekly - is it up to date and accurate? What follow-up is done with the information? 95 Surveillance Oversight Are all logs and reports up-to-date and analyzed on a real time basis to determine clusters, trends or potential outbreaks? Do you have current logs for employees who report illness? Is there a plan based on analysis of infection control data to include correction actions, education or other strategies? 96 32
Audits Hand Hygiene Audits Food Preparation Audits Personal Protective Equipment Audits Water Pass Audits Med Pass Audits Catheter Care Audits Peri-Care Audits Room Sanitization Audits Environmental Audits Dining Room Audits Linen Handling Audits 97 Audit Example 98 Well-trained and dedicated employees are the only sustainable source of competitive strength. - Robert Reich 99 33
Questions 100 Thank You! Sue LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT Director of Education Pathway Health 101 34