Framework for the Talk

Transcription

1 Lunch with Long-term Care Thinking Outside the Box Problem Solving Strategies Deb Patterson Burdsall MSN, RN-BC, CIC Infection Preventionist Lutheran Home/Lutheran Life Communities Arlington Heights, IL John A Hartford BAGNC Scholar Doctoral Candidate The University of Iowa College of Nursing Deborah-Burdsall@uiowa.edu Framework for the Talk Background of audience What would you like to talk about? Case Studies to kick it off Questions and some suggestions for where to find answers

2 Who do we have participating today? LTC Infection Preventionists Acute Care Infection Preventionist Infection Preventionists with responsibility for Home Care/Home Health/Adult Day Services/ Public Health Manufacturers/Vendors Other How Much Do You Like Doing Infection Prevention and Control?. I love it!!! It is my life 2. I like certain aspects 3. I tolerate the job 4. I really do not like the job 5. Who came up with this job anyway? 2

3 Infection Prevention in a nut shell What would you like to talk about today? Outbreaks (focus will be on respiratory and gastrointestinal outbreaks) Multi drug-resistant organisms Surveillance using SHEA/CDC/Stone, et al., 22 definitions None of these, I would just like to ask a question 3

4 Outbreaks It starts with a glance at the Influenza Positive Tests Reported to the CDC by WHO/NREVSS Collaborating Laboratories, National Summary 22-3 (show map) 4

5 went out December 5 th Please isolate or send home anyone who has respiratory symptoms promptly There is a lot of influenza activity starting in the southern states. Please keep an eye out. The goal is no outbreaks this season! Thank you High acute-care cost and higher mortality of hospitalization with pneumonia in Medicare beneficiaries One-half of pneumonia cases were treated in the hospital. 3 day mortality 3.4% with Healthcare associated pneumonia 6.4% with Community Associated Pneumonia Total medical costs $5,682 higher than matched control patients without pneumonia. The total annual excess cost of hospital-treated pneumonia as a primary diagnosis in the elderly fee-forservice Medicare population in 2 is estimated conservatively at greater than 7 billion dollars. Thomas CP, Ryan M, Chapman JD, StasonWB, Tompkins CP, SuayaJA, PolskyD, Mannino DM, Shepard DS. Incidence and cost of pneumonia in medicare beneficiaries. Chest. 22 Oct;42(4):

6 Reports of high local endemic rates I talked to the Infection Preventionist at a local suburban hospital who said they have never seen so much influenza A this early. Adjacent state is also experiencing outbreak situations. Sent out this notification to management and staff Got back this report from sister facility : All age groups are have been affected. Hospital had 6 some cases in the ER yesterday, local Nursing home has closed 2 halls. Schools are having problems also. Not all tested are positive for influenza A, but many are December Family Visits- Respiratory Etiquette signs, masks and hand gel at entrances December th. Patient A: Family Member visits mother with cold December 5 th. Patient B: Family has party for father/grandfather on other unit: Grandson has cold that he picked up in college during finals week December 5 th. Patient C: Family member visits getting over cold All the patients were vaccinated for influenza in October, 22. 6

7 Respiratory Illness Starts: December 3 th Patient A develops high fever, cough and respiratory symptoms: Swab is positive for Influenza A December 7 th : Patient B develops high fever, cough and respiratory symptoms: Swab is positive for influenza A Started on Tamiflu and placed on Droplet Precautions per HICPAC/CDC guidelines and policy and procedure December 7 th : Patient C develops fever, cough and respiratory symptoms: Swab is negative for influenza and RSV. Started on antibiotic and placed on Droplet Precautions 2 Units (42 beds each) put on Alert- Public Health notified. Christmas time is here. Christmas time is here Families growing near Fun for all Not those on call It s outbreak time of year Virus in the air Oseltamivir Signs and masks with blasts of hand hygiene to share 7

8 What does this look like to you? 7 All Influenza-like illness residents, families, employees Illustration by Ray Cruz, ALL 2 Poll: Transmission Based Precaution would you use? Standard Precautions Droplet Precautions Contact Precautions Both Contact and Droplet Precautions 8

9 New Information December 23: Separate unit now has patients with symptoms. Negative for influenza A and B Positive for RSV and adenovirus. What is the conundrum here? What are the CDC recommended Transmission Based Precautions for RSV and adenovirus? (considered epidemiologically important organisms). Droplet Precautions 2. Contact Precautions 9

10 Tricky Question for RSV Respiratory syncytial virus (RSV) infection, in infants, young children and immunocompromised adults Contact Precautions for duration of illness (P. 9 CDC/HICPAC) Pediatrics has used Contact Precautions during respiratory illness season Respiratory Diseases Adenoviruses Adenovirus can cause respiratory illness, gastroenteritis and conjunctivitis. Respiratory adenovirus infection range from the common cold syndrome to bronchitis and pneumonia Influenza A Potential for most severe illness Influenza B Usually less severe illness; may cause epidemics and severe illness in older adults Human Metapneumovirus small children, elderly and immunocompromised individuals are at risk of severe disease and hospitalization Respiratory syncytial (sin-sish-uhl) virus, or RSV recovery from RSV infection in to 2 weeks. However, infection can be severe in older adults

11 6 5 With Viral Identification Influenza A Influenza B Pos RSV Other Influenza B and RSV Mixed Respiratory March 23 7 Influenza B, RSV, and 2 unknown 2 cases 98 x5= 2/297 person days x = Rate of 6.73 ILI per person days 5 Influenza B Pos RSV Other 2 3

12 Viral Panel: PCR from Swab, aspirate or washing- Expensive and only available at large teaching or research institutions Human Metapneumovirus (hmpv) Rhinovirus Influenza A Influenza A subtype H Influenza A subtype H3 Influenza B Respiratory Syncytial Virus (RSV) A Respiratory Syncytial Virus (RSV) B Parainfluenza Virus Parainfluenza Virus 2 Parainfluenza Virus 3 Adenovirus Respiratory Complex Definition: Cough, weakness, fever, infiltrate Attack Rate 27% Confirmed HMPV Confirmed Combined HMPV and RSV Met Definition of Respiratory Complex: No Testing 4 2

13 Change the Ground Rules, Change the Approach Please share with all direct care staff. All Units- Residents and Patients with respiratory symptoms and a fever must stay in their rooms until evaluated please- place them on Droplet/Contact Precautions Please take resident temperatures BID to establish a baseline temperature Remember- a person with a 99 F temperature has a fever if their normal temperature is 97 F: 2 degrees over baseline is considered a fever People must be fever free for 48 hours on effective therapy to have Droplet/Contact discontinued or to come back to work. The respiratory illness on the first floor is not influenza (3 residents), but we do not want it to spread Control Measures- Posted Signs There are widespread respiratory and gastrointestinal illnesses circulating in the To protect the residents, patients, and you Please Wash your hands with soap and water for 5-3 seconds and use hand sanitizer frequently If you are recovering from an illness Please consider postponing your visit 7 days for adults days for children We suggest you wear a mask: Thank you for your support 3

14 And just when we thought we were out of the woods NORO, NORO, Norovirus Norovirus gastroenteritis Both criteria and 2 must be present Criteria : At least of the following GI sub criteria Diarrhea: 3 or more liquid or watery stools above what is normal for the resident within a 24 hour period Vomiting: 2 or more episodes within a 24 hour period Criteria 2: A stool specimen for which norovirus is positively detected by PCR, electron microscopy, enzyme immununoassay 4

15 Pay attention to residents, patients and staff who complain they are nauseated or who have loose stools or vomiting Send them home or keep them in their rooms. Immediately place anyone with these symptoms on Contact Precautions Whole loose stool specimens should be kept refrigerated at 39 F (4 C) send promptly and test for C-diff and Norovirus Persistent cleaning of all surfaces must be done (Suggest every few hours and after every episode of diarrhea, loose stools, or vomiting) Wash hands with soap and water for 5-3 seconds. Bleach/detergent wipes for surfaces that can tolerate bleach and Advanced Hydrogen Peroxide wipes for all surfaces (EPA approved for norovirus) 5

16 FOR COMPARISON 2 Norovirus Confirmed Gastrointestinal Outbreak Cases- Residents/453= 22% Attack Rate. (Bed number plus number of Medicare admissions) /6/ /3/ /2/ /27/ 2/4/ 2// 2/8/ 2/25/ //2 /8/2 /5/2 All staff, All shifts by the IP The staff were inserviced on all shifts by the IP Using Accelerated Hydrogen Peroxide wipes and Bleach/Detergent wipes on all surfaces frequently- CONTACT TIME Contact Precautions (with liberal use of masks) for anyone with nausea, vomiting or diarrhea Stool cultures for norovirus should be refrigerated. 6

17 (dementia unit): 2x of loose stools, or vomiting x 2 positive for norovirus Not meeting the surveillance case definition Responded with transmission based precautions Enhanced hand hygiene Enhanced environmental cleaning with the cluster. 2.5 Acute Gastroenteritis (AGE) Skilled Unit Control Measures started /6/23 One Confirmed Norovirus from /2/23 4 case of AGE 2.5 SX 2 per. Mov. Avg. (SX).5 7

18 Hand Sanitizer OR Soap and Water Wash or sanitize hands When coming to work and before going home When going room to room Before and after each resident contact After handling soiled equipment Before using gloves and after removing gloves F-44 Based Hand Hygiene Soap and Water Are visibly soiled (dirty) If they have come in contact with blood or other body fluids Before and after eating Before and after handling food Before and after assisting a resident with toileting after contact with a resident with infectious diarrhea After performing your own personal hygiene or personal use of the toilet F-44 Outbreak Prep Restrict movement on the units Respiratory Hygiene/Respiratory Etiquettemasks Hand hygiene Surface cleaning by everyone BID temperatures are helpful to establish baseline Prompt identification of symptoms In-room dining 8

19 Don t force or allow your employees to work sick: This is called Presenteeism Don t force those under your supervision to participate in group activities if they are not feeling well. You have resources: Use them! Guidelines and regulations State regulations State Public Health Officials 9

20 Urgent Threats Clostridium difficile Carbapenem-resistant Enterobacteriaceae (CRE) Drug-resistant Neisseria gonorrhoeae Serious Threats Multidrug-resistant Acinetobacter Drug-resistant Campylobacter Fluconazole-resistant Candida (a fungus) Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs) Vancomycin-resistant Enterococcus (VRE) Multidrug-resistant Pseudomonas aeruginosa Drug-resistant Nontyphoidal Salmonella Drug-resistant Salmonella Typhi Drug-resistant Shigella Methicillin-resistant Staphylococcus aureus(mrsa) Drug-resistant Streptococcus pneumoniae Drug-resistant tuberculosis 2

21 Concerning Threats Vancomycin-resistant Staphylococcus aureus (VRSA) Erythromycin-resistant Group A Streptococcus Clindamycin-resistant Group B Streptococcus MDRO Carbepenemase Resistant Enterobacteracae as an example 2

22 Case Study You receive a call saying a 67 year old woman needs rehabilitation She has a recent history of CRE sepsis. She has completed her treatment. She is status post Whipple (pancreaticoduodenectomy) CRE, or Carbapenem-resistant Enterobacteriaceae: (gram negative rods, usually Klebsiella or E.coli- The tricky thing about CRE is the resistance mechanisms can be shared across species of Gram-negative organisms supmeasures.html#facility-recommendations 22

23 Carbapenems are a class of antibiotics (Meripenem, Imipenem, etc) CRE are resistant to carbepenems, which are last chance antibiotics. CREs are also resistant to most commonly used antibiotics Infections are almost impossible to treat CRE bloodstream infections have about a 5% mortality rate Carbapenem-resistance can be transferred to many common gram-negative bacteria, like e-coli Hand sanitizer kills CRE CRE is not hard to kill in the environment, but dirty hands, dirty gloves and dirty equipment can spread them around How often do you see this organism? Experience with other MDROs suggests that it might be most effective to intervene on emerging MDROs when they first are recognized in a facility before they become common. For this reason facilities that rarely (e.g., per month) or never have patients admitted who are colonized or infected with CRE should be aggressive about controlling these organisms when they are identified. An example of one approach to CRE control in these settings is shown in Appendix B. 23

24 The C s of Precautions Clean Hands Clean Clothes Clean Equipment Clean Environment Contained Drainage Covered Wounds Careful use of antibiotics Comprehensive vaccination programs Cooperative interdisciplinary approach Revisiting McGeer, 22 Surveillance in LTC 24

25 Defining Infections Clinical Diagnosis vs. Surveillance Definitions The focus of a clinical diagnosis The person receiving care Identify health issues and devise a plan to treat disease and restore wellness The focus of a surveillance definition Common language and criteria for classification Compare apples to apples Standardize reporting National Healthcare Safety Network (NHSN) CDC s National Healthcare Safety Network Nation s most widely used healthcare-associated infection (HAI) tracking system Formerly NISS NHSN is the largest health care-associated infection reporting system in the United States;,5 healthcare facilities participate. Source : CDC 25

26 Goals and Purpose of NHSN NHSN provides medical facilities, states, regions, and the nation with data collection and reporting capabilities needed to: Identify infection prevention problems by facility, state, or specific quality improvement project Benchmark progress of infection prevention efforts Comply with state and federal public reporting mandates, and ultimately, Drive national progress toward elimination of HAIs. Source: CDC.gov SHEA/CDC Stone et al., 22 LTC Surveillance Definitions Respiratory Infections Cold Syndrome or Pharyngitis Influenza Like Illness Lower Respiratory Tract Infections Pneumonia Urinary Tract Infections Catherized Non-catherized 26

27 SHEA/CDC Stone et al., 22 LTC Surveillance Definitions Cellulitis, soft tissue, or wound infection Scabies Fungal oral or perioral and skin infections Herpes simplex infection Herpesvirus skin infection Conjunctivitis Gastroenteritis Norovirus gastroenteritis Clostridium difficile infection (CDI) Infection Prevention and Control in LTC is a Human issue, and needs to be dealt with within a biopsychosocial and spiritual framework Spiritual Social HUMAN Psychological Biological 27

28 Thank you!!!! 28