IP Programs : Bridging the Gap y ou are not alone

1. IP Programs: Bridging the Gapyou are not alone Neil Pascoe RN BSN CIC Epidemiologist Emerging and Infectious Disease Branch Infectious Disease Control Unit IIPW DFW APIC 10/24/13

2. Today’s Objectives • Compare regulatory requirements, standard of care, residents’ rights, oversight, and funding for different practice settings. • Discuss the identification of infectious disease, reporting requirements, and infection prevention and control measures. • Discuss the issues associated with the transfer of patients among facilities.

3. www.agencyabreviation.state.tx.us (www.dshs.state.tx.us)

5. DSHS Regulates • Abortion Facilities • Ambulatory Surgical Centers • Birthing Centers • Community Mental Health Centers • Comprehensive Out-Patient Rehabilitation Facilities • End Stage Renal Disease Facilities • Freestanding Emergency Medical Care Facilities • Hospitals - General • Hospitals - Psychiatric & Crisis Stabilization Units • Hospitals - Special • Laboratories - (CLIA) • Narcotic Treatment Clinics • Out-Patient Physical Therapy or Speech Pathology Services • Portable X-Ray Services • Rural Health Clinics • Special Care Facilities • Substance Abuse

6. DADS Regulates one • Adult Foster Care • Assisted Living Facilities • Home and Community-based Services • Primary Home Care • Hospice • Intermediate Care Facilities • Nursing Homes • Residential Care • State Supported Living Centers

7. DADS Regulates two • Area agencies on aging • Area agencies on aging transportation • Community Attendant Services • Community Based Alternatives • Community Living Assistance and Support Services • Consumer Directed Services • Consumer Managed Personal Assistance Services • Day Activity and Health Services • Deaf Blind with Multiple Disabilities • Emergency Response Services • Family Care • Guardianship Program • Home Delivered Meals • In-Home and Family Support • Local authorities • Medically Dependent Children Program • Pre-admission Screening and Resident Review • Program of All-Inclusive Care for the Elderly • Promoting Independence • Special Services to Persons with Disabilities • Special Services to Persons with Disabilities 24-Hour Shared Attendant Care • Texas Home Living

8. Similarities between DSHS and DADS • Both license multiple facility types • Both have a regulatory function • Both receive state and federal funds to operate • Both advocate for healthy Texans

9. Resident’s Rights • People moving into a LTCF become “residents” • Resident’s receiving care in a LTC facility are essentially at home

12. DADS IC Regulatory Enforcement • Federal 42 CFR §483.65 (F441) • Combines F441, 442, 443, 444 and 445 • State 40 TAC Part 1 Chapter 19 subchapter Q • 19.601 addresses IC requirements • Both require facilities to establish and maintain an IC program designed to provide a safe, sanitary, and comfortable environment to prevent the introduction and transmission of disease

13. http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=40&pt=1&ch=19http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=40&pt=1&ch=19

14. Provider Letters • 09-18 SHEA/APIC Recommendations for IC in LTCF • 12-17 vaccines for residents • 13-03 vaccines for HCW • DADS TRAINING • http://www.dads.state.tx.us/providers/Training/jointtraining.cfm

15. Is it bigger than a bread box?

16. Multi-drug Resistant Organisms: Organizing Your Interventions

17. Delivery of Healthcare ASC Acute Care LTACH LTC Home How do you maintain quality and continuity of care across settings?

18. Organizing - Surveillance • What is important in your facility? • Are certain residents high risk? • Documentation new residents status? • Infection or colonization with MDRO • Start small and keep it simple • Trends over time – run chart • Make data available to all staff

19. Organizing – Bundles, Checklists • A “bundle”  is a collection of processes (items) needed to effectively care for patients • The idea is to bundle together a small number of elements essential to improving clinical outcomes • A bundle should be relatively small and straightforward − a set of three to five practices or precautionary steps is ideal • A bundle is scored as all or none, no partial credit • Pilot’s check list – manage complexity • Institute for Healthcare Improvement

20. Clostridium Difficile • Discovered in 1935 by Hall & O’Toole. • Ubiquitous anaerobic gram-positive spore forming bacillus. • Causes 20-30% of all antibiotic associated diarrhea • Named “difficult clostridium” due to its resistance in isolation and growth. • In 1978 C. difficile produced toxin was found in patients with antibiotic-associated pseudomembranous colitis. Not all strains toxigenic. • Normally found in ~ 3% adults and 15-60% children < 1 yo, 10% to 20% of hospitalized patients • Rate and severity of C. difficile-associated diarrhea (CDI) increasing • New strain of C.difficile with increased resistance and virulence identified. LaMont, 2006

24. Prevention Strategies: Core • Contact Precautions for duration of diarrhea • Hand hygiene in compliance with CDC/WHO • Cleaning and disinfection of equipment and environment • Laboratory-based alert system for immediate notification of positive test results • Educate about CDI: HCP, housekeeping, administration, patients, families http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.

25. Prevention Strategies: Supplemental • Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)* • Presumptive isolation for symptomatic patients pending confirmation of CDI • Evaluate and optimize testing for CDI • Implement soap and water for hand hygiene before exiting room of a patient with CDI • Implement universal glove use on units with high CDI rates* • Use sodium hypochlorite (bleach) – containing agents for environmental cleaning • Implement an antimicrobial stewardship program * Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

26. Rationale for considering extending isolation beyond duration of diarrhea Bobulsky et al. Clin Infect Dis 2008;46:447-50.

27. Outline of a C. difficile “Bundle of Bundles” • Prompt identification and isolation of cases • at first suspicion • Laboratory testing • Hand hygiene • Environmental cleaning • Antimicrobial stewardship • Surveillance • Visitors • ???

28. LTCF and Reporting HAI Texas Healthcare-associated Infection and Preventable Adverse Event Reporting

30. NHSN (National Healthcare Safety Network) see packet material • Voluntary, secure, internet-based surveillance system • Integrates patient and healthcare personnel safety surveillance systems • Managed by the Division of Healthcare Quality Promotion (DHQP) at CDC. • Open to all types of healthcare facilities in the United States, including acute care hospitals, long term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers, and long term care facilities.

31. HAI Reporting View reports & comment CMS

32. Significance of Multi-Drug Resistant Microorganisms

33. MDRO definition • MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents • Although the names of certain MDROs describe resistance to only one agent (e.g., MRSA, VISA/VRSA, PRSP) • extended spectrum beta-lactamases (ESBLs) and others that are resistant to multiple classes of antimicrobial agents, are of particular concern • In addition to Escherichia coli and Klebsiella pneumoniae intrinsically resistant to the broadest-spectrum antimicrobial agents • Fairly common to the Gram negative bacteria • Acinetobacter baumannii resistant to all antimicrobial agents, or all except imipenem • Stenotrophomonas maltophilia - Burkholderia cepacia -Ralstonia pickettii http://www.cdc.gov/hicpac/mdro/mdro_2.html

34. CRE invades U.S. health care facilities

35. Spread of Carbapenemase Producers

36. Carbapenem-resistant Enterobacteriaceae (CRE) • Common cause of HAIs • Found in both acute care hospitals and long-term care settings • Since 2004, reports of CRE cases from LTACH and LTCF • Similar to the spread of other MDROs • Movement of colonized patients across the continuum of care contributes to regional transmission • Supported by mathematical modeling Urban C et al. Clin Infect Dis 2008;46:e127030 Endimiani A et al. J Antimicrob Chemother 2009;64:1102-1110. Smith DL et al. PNAS 2004;101:3709-14.

37. Inter-Facility Transmission of MDROs (Including CRE) Munoz-Price SL. Clin Infect Dis 2009;49:438-43.

38. Healthcare CommunityKPC outbreak, Chicago 2008 Clin Infect Dis 2011;53:532-40.

39. Urine Culture Result

40. Important Concepts for MDRO Transmission • Once introduced, transmission and persistence depend on: • availability of vulnerable patients • selective pressure exerted by AMR use • >potential for transmission with > numbers of colonized or infected patients ("colonization pressure") • impact of implementation and adherence to prevention efforts.

41. Important Concepts for MDRO Transmission 2 • Patients vulnerable to colonization and infection include • severe disease • compromised host defenses from underlying medical conditions • recent surgery • or indwelling medical devices (e.g., urinary catheters, central lines, or endotracheal tubes • Hospitalized- esp. in ICU

42. http://www.cdc.gov/HAI/organisms/cre/

43. http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdfhttp://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf http://www.cdc.gov/drugresistance/index.html http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf

44. 94% 6%

45. Epidemiologically Important • Common cause of infection • Multidrug-resistant, limited treatment options • Capable of transferring resistance • High mortality rates for invasive infections • Potential to spread out of healthcare settings

49. What Can Healthcare Professionals Do? • Know if patients in your facility have CRE. • Request immediate alerts when the lab identifies CRE. • Alert the receiving facility when a patient with CRE transfers out, and find out when a patient with CRE transfers into your facility. • Protect your patients from CRE. • Follow contact precautions and hand hygiene recommendations when treating patients with CRE.

50. What Can Healthcare Professionals Do? • Dedicate rooms, staff, and equipment to patients with CRE. • Prescribe antibiotics wisely (Get Smart for Healthcare). • Remove temporary medical devices such as catheters and ventilators from patients as soon as possible. • Report cases promptly • Communicate!