Methicillin resistant Staphylococcus aureus (MRSA) in Long-term Care (LTC): Another Piece of the Puzzle

1. Methicillin resistant Staphylococcus aureus (MRSA) in Long-term Care (LTC):Another Piece of the Puzzle Susan M. Kellie, MD, MPH Associate Professor of Medicine Hospital Epidemiologist, University of New Mexico Health Sciences Center (UNMHSC) and New Mexico Veterans Affairs Health Care System (NMVAHCS)

2. Hospital admission prevalence 6 percent to 10 percent Prevalence: 1.5 percent colonized, 3 percent for those over 60* MRSA “hot spots” *National Health and Nutrition Examination Survey Data

3. Community-acquired MRSA (CAMRSA) causes severe infections in young healthy persons CAMRSA strains are moving into acute care hospitals and back into LTC facilities, putting a vulnerable population at risk for novel syndromes, such as severe skin and soft tissue infections and post-influenza necrotizing pneumonia Controlling MRSA in LTC

4. Epidemiology of Health Care-Associated Bloodstream Infections Caused by MRSA USA 300 in Three Affiliated Hospitals in Denver • Of 330 cases of MRSA bloodstream infection occurring between 2003 and 2007, 87 percent were health care-associated* • USA 300 was 62 percent, 19 percent and 36 percent for community-onset cases, and 33 percent, 3 percent and 33 percent for hospital-onset cases, with an increasing trend • The local safety-net hospital had the highest rates (University of Colorado) • Infection Control and Hospital Epidemiology, March 2009 * Using the Centers for Disease Control and Prevention (CDC) definition for historical criteria

5. Community environments Healthcare environments Skin and soft tissue infections due to USA 300 Healthcare-associated strains of MRSA Invasive MRSA infections Colonized persons in the community Colonized persons in the community Colonized patients

6. Most Common Health Care Risk Factors • Among patients with community-onset infections: • A history of hospitalization (76.6%) • LTC residence (38.5%) • History of surgery (37.0%) • MRSA infection or colonization (30.3%) Klevens. Invasive MRSA infections in the US. JAMA October 17, 2007

7. Most Common Health Care Risk Factors • Among patients with hospital-onset infections: • History of hospitalization (57.7%) • History of surgery (37.6%) • LTC residence (21.9%) • MRSA infection or colonization (17.4%) • People who were aged 65 years or older had the highest incidence rates (127.7 per 100,000) Klevens. Invasive MRSA infections in the US. JAMA October 17, 2007

8. Rates of Colonization in Patients Admitted to Albuquerque Facilities • VA: All patients undergo active surveillance testing with MRSA polymerase chain reaction (PCR) on admission • Rates of colonization are 8 percent to 16 percent each month • Rate of progression to clinical isolate is about 3 percent, and to an infection meeting CDC criteria around 1.5 percent • UNM: All adult patients admitted to intensive care units (ICUs) are tested: • Trauma-Surgical: 10 percent positive • Medical: 8 percent positive • Neuroscience ICU: 7 percent positive • Transmission rates in these units: 1 percent to 3 percent

9. Point Prevalence Survey of MRSA Association for Professionals in Infection Control and Epidemiology (APIC), 2006; American Journal of Infection Control, December 2007

10. MRSA Rates in LTC Settings • MRSA colonization is prevalent: • In two of the most common sites of colonization, nares and wounds, colonization rates range from 8 percent to 53 percent, and 30 percent to 82 percent, respectively • Bradley. Methicillin-resistant Staphylococcus aureus: Long-term care concerns. Am J Med 1999, vol. 106, no 5A (54 p.)  (40 ref.), pp. 2-10. Department of the Veterans Affairs Medical Center, and University of Michigan, Ann Arbor, Michigan

11. Current MRSA Colonization Prevalence Rates in Nine VA LTC Facilities (2007)

12. Questions from LTC • How do we know they have MRSA? • So we know they have MRSA—what do we do about it? • How do we implement infection control for MRSA colonized or infected patients? • And why should we go to this effort?

13. Why Control MRSA in Non-acute Care Settings? • MRSA is becoming more resistant and deadly • Prolonged colonization is not benign: • MRSA-colonized patients who have prolonged carriage (>1 year) have a 23 percent risk of progression to infection with a 25 percent mortality* • MRSA doubles length of stay and cost in acute care • * Datta, Huang. Clinical Infectious Diseases 2008; 47:176–81

14. Why Control MRSA in Non-acute Care Settings? • Areas where LTC and referral facilities have collaborated have seen a drop in MRSA prevalence (NW Chicago, Wisconsin) • Expectations are changing: APIC will publish an “Elimination Guide for MRSA in LTC” in 2009 • Epidemiologic metrics will bring the focus onto transitions in care and community reservoirs of MRSA

15. Key Issues for LTC • Communication at and post-discharge and again at readmission to acute care • Perform risk assessment at the facility level and patient level • Institute Standard Precautions for all patients

16. Key Issues for LTC • Institute Extended Precautions (Contact Precautions) for patients at risk of spreading MRSA to other patients • Consider source control • Educate staff, patients and families • Be able to articulate a clear rationale for infection control in the facility and demonstrate consistency from all providers

17. Communication • Need standardized communication regarding multidrug resistant organism (MDRO) colonization and history (including C. difficile) in all transfers from and to acute care • Need standardized follow-up communication for any tests which may turn positive after the patient’s discharge from acute care (i.e., the “discharge swab” used to determine rate of transmission in acute care)

18. Continuity of Care Document (CCD) • A statewide, mandatory use “transfer form” (New Jersey pilot) • Inpatient/resident transfers between licensed health care facilities and programs Selective Exclusions • Emergency Department \] Emergency Department • Emergency Department \] Return to LTC • New Born, Others

19. Advantages of Universal CCD Communications between providers Efficiency of process Quality of care at transition Patient/resident/family satisfaction Work Smarter, Not Harder, It’s Easier!

20. New Jersey CCD Highlights • Two Pages (may change) • Page one – Essential information • Page two – Desirable information • No Duplication: Attach related documents • Reason(s) for transfer • Follow-up care/appointment details • Decision maker: identity/contact information • If questions, who to call?

21. CONTINUITY OF CARE DOCUMENT UNIVERSAL TRANSFER FORM (08/2007) TRANSFER FROM (Facility/Program): _____________________________________________________________ _____________________________________________________________ Place label here (Facility/Program) TRANSFER TO (Facility/Program): _______________________________________________________ _______________________________________________________ Date of transfer________________________________________

22. Continued…

23. Clear Purpose: Patients’ right to continuity of care Broad outreach to stake holders Transparent, democratic process Trial “test drive” Initial Formal – arms length Get it right the first time Prioritize content: less is more Selective exclusions Power over purpose Force the issue Elite, closed door strategy No “test drive” Don’t let the “perfect” halt the “good” NJ CCD Development Process What Worked What to Avoid

24. Federal Centers for Medicare & Medicaid Services – Post Acute Care Changes Uniform Patient Assessment Form and Continuity Assessment Record and Evaluation (CARE) project with on-line record

25. Risk Assessment in LTC • Review your population • Referring hospitals • Length of stay • Indwelling devices • SNF component for IV therapy • Wound care • Dialysis • Numbers of patients with known MRSA, and newly identified cases

26. Risk Assessment in LTC • In general, the higher the need for assistance with activities of daily living (ADLs), the greater the risk for MRSA colonization • The more wounds, tracheostomies, etc., the greater the risk for MRSA spread from the patient • The more indwelling devices, the greater the risk of invasive infection

27. CDC MDRO Guideline 2006: Applies to all health care settings, “LTC facilities should seek consultation” CDC Isolation Guideline 2007: Discusses LTC facilities together with acute care Only exception is to guide patient cohorting in residential settings Society for Healthcare Epidemiology of America (SHEA)/APIC Guideline for Infection Control in Long Term Care 2008: Addresses cohorting criteria and creation of two tiers of precautions for MDRO-positive patients States and VA have created more specific guidance Guidelines for Control of MDRO in LTC Facilities

28. Barriers to Effective Management of MRSA and Other MDROs • Hand hygiene requires alcohol hand disinfectant provided at the point of care • Misconceptions about rules on placement of alcohol hand disinfectant • Misconceptions about “Standard Precautions” • Managing MRSA in non-acute settings • Communal living and group activities • Room placement of patients with MDRO

29. A 24-year-old man who had quadriplegia due to a traumatic spinal cord injury was found on routine surveillance cultures to have MRSA colonization of his anterior nares An imprint of a health care worker's ungloved hand was obtained for culture after the worker had performed an abdominal examination of the patient After the worker's hand had been cleaned with alcohol foam, another hand imprint was obtained, and the resulting culture was negative for MRSA These images illustrate the critical importance of hand hygiene in caring for patients, including those not known to carry antibiotic-resistant pathogens The Hands Give It Away New England Journal of Medicine, Jan. 15, 2009

30. Standard Precautions: World Health Organization Handout • Standard precautions: Not just to prevent exposure to bloodborne pathogens, they are a cohesive system to prevent the spread of infection • Key elements: hand hygiene before and after every patient contact • Add gloves for any contact with non-intact skin, mucous membranes, excretions or secretions • Add gown to prevent soiling of clothing in settings where splashes may occur

31. VA Community Living Centers • Active surveillance testing of all patients with unknown MRSA status and rescreening of all patients in six months • Triage patients into high and low risk for MRSA transmission to others, based on ability to perform hand hygiene and containment of drainage from all indwelling devices • Guidelines are predicated on full implementation and understanding of standard precautions and patients’ ability to perform hand hygiene

32. Assumes extensive contamination of environment MRSA contaminates clothing, stethoscopes, etc. Gown and glove should be donned on room entry, stethoscope dedicated or wiped High-touch items should be wiped down daily Contact Precautions

33. Patients with contained secretions who can do hand hygiene (or have it done to them) can leave their rooms Cohorting guidelines: MRSA patients can be cohorted together Communal activities: Encourage frequent hand hygiene for residents Key Adaptations in Post-acute Care

34. Standard Precautions • MostLTC residents with MDROs can be cared for using Standard Precautions • Standard Precautions and hand antisepsis are adequate for LTC residents who have contained MDRO-colonized or infected secretions/excretions • Contact precautions should be added for residents with uncontained secretions or drainage

35. Room Placement • Norequirement that residents with MDROs must be placed in a private room; residents with MDROs may be placed with appropriate roommates • An appropriate roommate is either: • A resident with the sameMDRO(cohorting) • Ora resident who has intact skin with no significant open wounds or breaks in skin (superficial tears or breaks in the skin such as minor scratches, would be acceptable), has no invasive devices, indwelling vascular or urinary catheters or drainage devices, and • Is not significantly immunocompromised andis not colonized or infected with a different MDRO

36. Barriers to Hand Gel-life Safety Issues • Is it a hazard to patients? • Could it be ingested? • What about the fire rules? • Expert advice on the placement of alcohol hand gel

37. Can we decolonize patients in LTC? Mupirocin alone is moderately effective in residents without large wounds: a two-week regimen was used Eradicated colonization in 93 percent of residents At 90 days, 61 percent of the residents in the mupirocin group remained decolonized A trend toward reduction in infections was seen with mupirocin treatment Source Control Mupirocin-Based Decolonization of Staphylococcus aureus Carriers in Residents of 2 Long-Term Care Facilities: A Randomized, Double-Blind, Placebo-Controlled Trial. Mody et al. Clinical Infectious Diseases 2003; 37:1467–74

38. Skin Contamination and Environmental/Health Care Worker Contamination by or Patient Acquisition of Vancomycin-Resistant Enterococci (VRE) Vernon, M. O. et al. Arch Intern Med 2006;166:306-312.

39. Discussion on the key issues and needs Communication tools Education of staff, patients and families Detailed guidance on implementation of standard and extended precautions in post-acute care settings (Minnesota guideline) Next Steps