The Power of Surveillance

1. The Power of Surveillance Improving resident outcomes through tracking and preventing infections Martha Harris, BS, M(ASCP), CIC

2. Learning Objectives • Describe the current and future stresses placed on long-term care facilities (LTCFs) regarding healthcare-associated infections (HAIs) • List the surveillance components of an effective Infection Control Program • Identify common sites for infection in your population • Develop program to collect, review, and report HAI data • Describe various external reporting requirements • Develop resource network

3. State of HAIs in LTCFs • More than 1.5 million residents reside in United States nursing homes. In recent years, the acuity of illness of nursing home residents has increased. • LTCF residents have a risk of developing healthcare-associated infections (HAIs) similar tothat seen in acute care hospital patients. SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility July 2008

4. HAI Data in LTCFs • In LTCFs, it is estimated that there are 1.6 million to 3.8 million infections occur each year. • The overall infection rate in LTCFs ranges from 1.8 to 13.5 infections per 1,000 resident-care days. • The high number of infection control deficiency citations (F-Tag 441) in NHs highlight the need for a greater focus on infection prevention (AJIC 2011) • There are currently little HAI data and no national surveillance systems for LTCF infections • Estimates have been calculated based on research studies and outbreak reports from the medical literature. SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility - July 2008 Nursing home deficiency citations for infection control – AJIC – May 2011

5. Future State of LTCFs • The US population aged 65 to 85 years is increasing rapidly, and the population aged 85 years and older is expected to double by 2030. • One of every 4 persons who reaches the age of 65 can be expected to spend part of his or her life in a nursing home; more people occupy nursing home beds than acute care hospital beds in the US. SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility July 2008

6. HAI Surveillance in Acute Care Hospitals • 1968 – CDC begins acute hospital HAI surveillance on a national level • 1970 – National Nosocomial Infection Surveillance system (NNIS) • 2005 – National Healthcare Safety Network (NHSN) • 2008 – CMS reduced payment for HAI conditions (HACs)

7. HAI Surveillance in LTCFs • Currently, no mandate for reporting of HAIs in LTCFs. • NHSN modules are being developed – but use is totally voluntary at this point in time • When available, using NHSN may be beneficial: • Provide standardization • Make benchmarking possible • Improve quality of data • Help ease the learning curve by starting use early

8. NHSN LTC Module (Draft) DRAFT

9. LTC Infection Control Program • Designated coordinator • Policy and procedure formation • Surveillance • Education of staff and volunteers in infection control methods • Antibiotic monitoring • Reporting outbreaks and designated diseases to public health • Quality improvement • Environmental review

10. Surveillance Program • Ongoing system for collection of data on infections and antibiotic use in facility • Program should include: • Definitions of HAIs • Characteristics of population at risk • Steady data streams • Microbiology reports • Antibiotic usage reports • Device days

11. Definition of Infection • Active Infection: • A resident with an infectionwho is culture positive and canexhibit the following symptoms: fever, elevated white blood cell count, inflammation, pus in wound or surgical site, or increased secretions. • Colonization: • A resident who is also culture positive but does not exhibit signs and symptoms of infection. The resident can be a source of transmission of the organism to staff and to other residents, directly or indirectly.

12. McGeer’s Surveillance Criteria • Compiled in 1991 • Used primarily for LTC infection surveillance • Published in Am J Infect Control 19(1): 1-7, 1991 • No study to determine reliability or validity • No established benchmarks • No risk classifications • CDC is currently working to help update the McGeer criteria and incorporate it into NHSN for LTCFs.

13. McGeer’s Surveillance Criteria

14. Surveillance Definitions • Acute care definitions should not necessarily be used in LTCFs • All symptoms must be new or acutely worse • Chronic symptoms should not be used • Non-infectious causes of signs/symptoms (S/S) should be considered first • Identification of an infection should not be based on one piece of evidence • Physician diagnosis should be accompanied by compatible S/S of infection

15. Risk of Infection Inherent in the Elderly • There are three basic groups of infection risk factors: • Resident’s physical risk factors • Resident’s psychological risk factors • Device-associated risk factors • Each risk factor contributes to an increased risk of acquiring an HAI for that individual and within the LTC population

16. Most Common HAIs • Urinary tract infections • Catheterization, dehydration • Respiratory infections • Influenza • Skin and soft tissue infections • Ulcers due to lack of mobility, skin breakdown • Gastrointestinal infections • Clostridium difficile, Norovirus • Systematic infections • IV lines or tubes

17. Most Frequent Infections by Facility Type: Virginia CAUTI= catheter-associated urinary tract infection UTI= urinary tract infection; not including CAUTI CLABSI= central line-associated bloodstream infections SST= skin and soft tissue infections VAP = ventilator-associated pneumonia Pneumonia: not including VAPs MRSA= methicillin-resistant Staphylococcus aureus

18. Data Collection Challenges • Inconsistencies may include: • Application of definitions • Use of microbiological or laboratory tests to support infection diagnosis • Collection of device and patient days • Appropriate documentation of resident’s S/S • Use of one central laboratory • Lack of previous medical history records from other healthcare facilities makes “Present on admission” assessment difficult.

19. Surveillance Data • Analysis of data related to resident illness: • Must be systematic and standardized • Will establish facility baselines but are limited to what data are collected • Can identify areas of strength or weakness in the IC program • Raw datacan not be used for surveillance reports since they cannot be compared over time.

20. HAI Rates • Numeratoris the number of HAIs identified • Denominatoris the population at risk • Careful: 1,000 is not always the constant Examples provided by Mary Andrus, BA, RN, CIC

21. Incidence Rate • Number of new cases per population in a given time period Examples provided by Mary Andrus, BA, RN, CIC

22. Line Listing

23. Data Charting Example of the infection prevalence rates for the 4 units in one LTC facility unit for January and February.

24. Run Chart In-services on correct perineal care URI – residents with productive cough, elevated temperature, or hospitalization captured HAI Rate per 1000 resident days Calendar Months

25. Using Data to Improve Resident Outcomes HAI Rate per 1000 resident days Calendar Months for 2008-2010

26. Internal Reporting • Share data with internal stakeholders • Administrators, nurses, environmental services, etc. • To help maintain situational awareness and obtain support • To help identify possible challenging areas and possible solutions • To encourage ownership of both the problems and solutions • Data presentation should be customized for the intended audience • Timely, focused data is often preferred

27. External Reporting • If the HAI occurs within 48 hours or 3 calendar days of admission, report the HAI to the facility the patient/ resident was transferred from • Report infections associated with surgical procedures to the facility where the operation was performed if the HAI occurs within • 30 days and there was not an implant • 1 year and there was an implant

28. External Reporting • Report any epidemiologically significant infections to your local health department (Examples below. Full list available from HD). • Hepatitis B and C (acute and chronic) • MRSA from sterile site • Pertussis • Foodborne illness • Tuberculosis, active disease • All suspected and/or confirmed outbreaks • Norovirus • Influenza

29. Additional Surveillance • Resident influenza and pneumovax vaccinations • Staff vaccinations and immunization status • Blood and body fluid exposures • Process improvement measures • Hand hygiene • Device utilization ratio • Compliance with personal protective equipment (PPE) • Antimicrobial use

30. Successful Strategies for Infection Prevention in Assisted Living Facilities and Nursing Homes Toolkit Available from your local health department. Full of education on infection prevention and control that you can use TODAY to improve your program.

31. Logs in the Toolkit • Monitoring compliance • Hand hygiene • Environmental cleaning checklist • Cleaning and disinfection for blood spills or other potentially infectious bodily fluids • Blood glucose monitoring • Logs • Vaccination • Resident immunization record, resident influenza vaccination log, general vaccination log • Illness • Monthly surveillance tracking sheet, gastrointestinal illness log, respiratory illness log, etc.

32. Environmental Cleaning: Measuring Compliance Environmental Checklist Environmental Checklist: Blood Spills

33. Individual Immunization Record Resident Immunization Record Resident Flu Vaccination Log

34. Additional Resources • Hospital IPs • Local Health Department • VDH HAI Team • State organizations • Centers for Disease Control and Prevention: • Clinical guidelines and surveillance definitions • Disease-specific guidance (bloodborne pathogens, norovirus, influenza, TB, MDROs, UTIs) • Environmental cleaning and disinfection • Hand hygiene • Immunizations and employee health • Isolation precautions • Licensure and reporting regulations

35. Use Your Local Resources Local Hospital IPs APIC Virginia Members Contacts at other LTC facilities Local Health Department

36. Use Your Local Resources

37. Summary • Surveillance is the best way to know: • What is going on in your facility • What your infection baseline is so you can identify an outbreak more quickly • How well your infection prevention programs are working • What areas you need to provide education for your staff • Public reporting of LTC HAIs is not currently required but may be a part of your future