BEHAVIORAL HEALTH & LTC Mary Ann Kellar, RN, MA, CHES, IC March 2011
CDC Isolation Guidelines-adapting to special environments MDRO s CMS-F 441 C.difficile Norovirus
Federal (CMS), State & Joint Commission Regulations & Guidelines MDRO s- C.Diff, MRSA, ESBL Reimbursement issues Media attention >consumer activism Aging population National Quality Forum-5 of 21 measures
surveillance outbreak control isolation and precaution, policies and procedure, education resident health program employee health program antibiotic review, disease reporting other functions such as quality improvement and safety
The long-term care setting is unique in several aspects. The facility is "home" for most residents. Infection control measures must be balanced with the residents' need for socialization and mobility: quality of life issues.
Behaviors often prevent traditional IC measures Severely mentally ill presents and increase infection risk Homeless, drug use, communicable diseases Accreditation/state regs often acute care oriented
Perform ICRA-focus on highest IC risks Every pt. must be individually assessed MDRO assessment- active & H/O Individual IC care plan with nursing staff Behavioral Contracts for higher functioning pts Do medical needs (stringent isolation) outweigh psych needs??
CDC/HICPAC Expanded Isolation Guidelines 2007 Replaced Outdated 1996 Document
Outbreaks of hepatitis B and C in ambulatory settings>need to emphasize safe injection practices Evidence that environmental controls (protective environment) decrease fungal infections in immunocompromised patients Continued prevalence of HAI s- primary reason for revising Isolation Guidelines
Discuss surveillance practices Transmission-based precautionsunchanged Organizational systems, staffing, and safety culture effect IC practices i.e.-(administrative involvement) Use of PPE
Expanded to alternative health-care settings (LTC, Dialysis, Surgicenters) Address respiratory hygiene/mask use Emergence of MRDOs and bioterrorism
Health-care transition from acute care to rehab, sub-acute and LTC New pathogens-sars Evolving pathogens-c. Diff, norovirus, MRSA Expound on success of Standard Precautions
Expand standard precautions to include respiratory hygiene and cough etiquette Mask use when performing certain high-risk, prolonged procedures HAI-Healthcare Associated Infection- nosocomial for acute care only
Provide more focus on administrative support of infection control (IC) programs, in particular the importance of ICP and nurse staffing levels
The document is 225 pages and includes the following sections: A review of scientific data about the transmission of infectious agents in healthcare settings A summary of what is needed to prevent transmission of infectious agents Type and duration of precautions that are recommended for specific infections and conditions
How do you cohort when there are placement challenges? Single rooms are seldom available. Residents often have several MDROs. How long do we maintain restrictions?
In acute care: Contact Precautions = stay in room; gown and gloves to enter. In LTC: Shared activities and common areas Logistical challenges Long term vs. short stay
Place patients or residents with MDROs in a single room if possible, particularly if they have conditions that may facilitate transmission such as uncontained secretions or excretions.
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. Category II
For relatively healthy resident (e.g., mainly independent) follow Standard Precautions, making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes/bags. Category II
For ill residents (e.g., those totally dependent upon health-care personnel for health care and activities of daily living, ventilatordependent) and for those residents whose infected secretions or drainage cannot be contained, use Contact Precautions in addition to Standard Precautions. Category II
Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale Allows individualizing of policies for patient and environment
Consider the prevalence or incidence of MDRO s in the facility when making the decision to implement or modify Contact Precautions in addition to Standard Precautions
CDC Category II For ill residents and for those residents whose infected secretions or drainage cannot be contained, use Contact Precautions in addition to Standard Precautions. Category II
http://www.cdc.gov/ncidod/dhqp/index.ht ml
In 2009, the US Centers for Medicare and Medicaid Services (CMS) issued revisions to its Interpretive Guidelines for Long-term Care Facilities. The revision combined F-tags 441, 442, 443, 444 and 445 into one tag, 441, for the purpose of consolidating all the infection control provisions into a single location.
The revisions do not include any CMS regulatory changes. The level of detail included in the newly issued guidance is substantial.
Put MDRO patient with patient at lower risk for acquiring infection (no wound, no tubes, no ABT, not bed bound). Lower risk of adverse outcome if acquire infection Likely to have a short stay in the facility
1. COGNITIVITY - understands directions 2. COOPERATIVE willing & able to follow directions 3. CONTINENT - urine and stool 4. CONTAINED- wound drainage 5. CLEANLINESS- personal hygiene maintained
policies required for infection control programs & for preventing the spread of infection policies for the handling, storing, processing, and transporting of linens CDC definitions investigative protocol for surveyors compliance criteria a brief overview of the role infections play in nursing facilities
http://www.cms.hhs.gov/transmittals/ downloads/r51soma.pdf
Focus areas for IC- Glucometer- cleaning after every use Insulin pens/insulin storage-no touch!! (labeled separate plastic bags) Hand Hygiene Medication administration Dressing change policy- gloves, soiled dressings
SNFs must to look at their infection control and prevention programs and determine what needs to be changed to comply with the revised guidance. Lower deficiencies (A-C) do not apply to this F-tag. Facilities will receive higher deficiencies (D-L) for noncompliance.
Inability to prevent C. difficile associated disease (CDAD) in high-risk settings; Lack of a sensitive and rapid diagnostic test for CDAD; Inability to prevent recurrence of CDAD: up to 60%; Inability to effectively treat fulminate disease; Colonization, asymptomatic carriers.
Hyper virulent strains(bi/nap1/127)> outbreaks 16 times more toxin production Survival in vegetative form Ineffective alcohol gels and standard hospital disinfectants Residents from multiple referral sites Asymptomatic carriers- 51% of LTC residents asymptomatic carriers* 20% mortality rate if over age 75 *Riggs, et, al, Clin. Inf.Dis 2007;45 (8)
CDI due to recent (re)acquisition of C. difficile Incubation period unknown <7 days to several weeks? Antimicrobial exposure may or may not precede acquisition The two appear to be in proximity
Antibiotic use advanced age Co-morbidities Feeding tubes Proton pump inhibitors Hospitalization (>ABT)
The incidence of CDI was significantly higher among patients admitted to a room in which the previous occupant had had CDI than among patients admitted to a room in which the previous occupant had not had CDI (11.0% vs. 4.6%; P=0.002). Dubberke ER et al. Development and validation of a Clostridium difficile infection risk prediction model. Infect Control Hosp Epidemiol 2011 Feb 21; [e-pub ahead of print]. (http://www.jstor.org/stable/10.1086/658944)
Educate, Educate, Educate!!! Housekeeping- primary defense Educate residents- report environmental soiling & reporting of C.diff S&S Increase vigilance on memory support units- may require extra staff to monitor Immediate isolation if suspected-staff knows before lab results!!
Communication to departments- line list Cohort if no private rooms Frequently touched surfaces- bleach Keep open room available for isolation Handwashing- no waterless products Contact Isolation- gloves and gowns if soiling likely PCR testing- toxin test slow; less than 60% accuracy
SHEA IDSA Guideline Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Infect Control Hosp Epidemiol 2010;31:000 000 2010 by The Society for Healthcare Epidemiology of America
Updated Norovirus Outbreak Management and Disease Prevention Guidelines Morbidity and Mortality Weekly Report (MMWR) March 4, 2011 / 60(RR03);1-15