Objectives. Overview 9/14/2015. Infection Control: Concrete Solutions for System Review and Oversight

Transcription

1 Infection Control: Concrete Solutions for System Review and Oversight Presented by: Susan LaGrange, RN, BSN, NHA, CDONA Director of Education Pathway Health 1 Objectives Upon completion of the program, participants will be able to: 1. Identify the specific components of an Infection Control Program. 2. Describe specific education and accountability components of the program. 3. Identify how to put an audit system in place for all departments to monitor and manage compliance. 2 Overview Infections are a significant source of morbidity and mortality for nursing home residents.. Account for up to half of all nursing home resident transfers to hospitals Infections result in an estimated 150, ,000 admissions per year to the hospital at a cost of between $673 million to $2 billion annually CMS State Operations Manual, Appendix PP, F

2 F441 Federal Regulation Consistently in top 3 Citation Nationwide! Infection Control The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection 4 Intent of F441 Regulation The intent of this regulation that the facility Develops, implements and maintains an Infection Prevention and Control Program in order to Prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility No longer control! Now PREVENTION! 5 Infection Control Program The facility must establish an Infection Control Program under which it: Investigates, controls, and prevents infections in the facility Decides what procedures, such as isolation, should be applied to an individual resident Maintains a record of incidents and corrective actions related to infections 6 2

3 Proposed Rule Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities; Proposed Rule /pdf/ pdf 7 Proposed Rule Will need written standards, P&P s to include Surveillance Reporting Standard and transmission based precautions Isolation When to prohibit employees with communicable diseases or infected skin lesions may work Hand Hygiene 8 Proposed Rule The facility must establish an IPCP that includes: A system for prevention, identification, reporting, investigating and controlling infections and communicable diseases for residents, staff, volunteers, visitors and others based upon the facility assessment 9 3

4 Proposed Rule Antibiotic Stewardship Program System to record incidents under your IPCP along with corrective actions 10 Proposed Rule Infection Prevention and Control Officer (IPCO): Facility must designate IPCP is a major responsibility A clinician who works at least part-time at the facility Must have specialized training in Infection Prevention and Control beyond their initial professional degree Must participate and be a member of the QA&A committee Influenza and pneumococcal information 11 Prevention is the Key!!! 12 4

5 Recent Survey Citations Examples of Survey Citations Facility failed to prevent transmission of influenza outbreak by failure to: Cohort residents and Staff Stop Activities Close Main Dining Room Service Analyze Data Maintain adequate records of employees for safe return to work 14 Examples of Survey Citations GI Symptoms or Norovirus: Facility did not have policies regarding GI outbreaks Facility not quarantined when residents throughout the building presented with symptoms Local Health Department not called Medical Director not notified Staff continued to float throughout the building New Admissions not limited Hand washing (staff and resident) No documentation that staff were not allowed to return to work until symptom free for 48 hours 15 5

6 Examples of Survey Citations Hand washing/gloving: Staff providing cares and not removing gloves and washing hands prior to touching items in room or obtaining clothes in closets/drawers 16 Survey Citations for F441 Peri-care Tracking of staff attendance when calling in (actually wanted a log of all call-ins and when they came back to work) Mapping of infections on a facility grid Proper storage of items in the dietary refrigerators Bath towels on the toilet tank in tub room Red hazard bag on floor in hall 17 Survey Citations for F441 Blood glucose monitors not disinfected between each use. (Following manufacturer s recommendations) Catheter drainage bag on floor Gait belt used resident on isolation Dressing changes- technique Peri-wipes and skin cream contaminated Failure to have an IC Program Did not clean and disinfect electric razors 18 6

7 Recent Survey Citations Did not clean resident s finger before using lancet Did not have an assigned person for infection control program Lack of surveillance and analysis of data to determine clusters, prevalent organisms, or rate of infections Did not wash hands between each resident at med pass Dumping soiled water into sink 19 Recent Survey Citations Facility failed to have a comprehensive antibiotic stewardship program in place Touching barrier cream tube without removing gloves, washing hands and reapplying gloves and put contaminated tube in drawer after use Not using paper towels to turn off sink handles 20 Infection Control Focus on Prevention 21 7

8 Admission Screening Risk Factors Antibiotic use past 30 days Current symptoms or diagnosis Cultures taken and results Immunization history Duration of indwelling catheter Presence of MDROs Prior infection 2-step mantoux- history of positive reaction 22 Components - Infection Control Program - F441 Program Development and Oversight Policies and Procedures Infection Preventionist Surveillance Documentation Monitoring Data Analysis Communicable Disease Reporting Education Antibiotic Review and Stewardship Program Development and Oversight Facility program oversight should collaboratively include: Infection Preventionist *The proposed rule=ipco Administrator Medical Director (or a designee) Director of Nursing Other staff as appropriate

9 Medical Director Roles & Responsibilities Advisory Criteria for identifying infections How to distinguish facility acquired from community-acquired Appropriate surveillance activities Data collection instruments Antibiotic usage Surveillance forms 25 Have You Reviewed Your P&P When was the last time your Infection Control Policies and Procedures were reviewed and revised If you have revised the P&P s, how have we educated the staff Have we audited the system Are the policy and procedures based on best practice guidelines 26 Policy and Procedure Consistent with regulations and standards of practice Provide guidance to staff on steps to follow Should be in a place where easily accessible to all staff New changes in the industry should be researched and included in the P&P 27 9

10 Policy & Procedures Examples Use of standard precautions facility-wide Use of transmission-based precautions when indicated Define surveillance activities Require that staff use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated Prohibit direct resident contact by an employee who has an infected skin lesion or communicable disease Housekeeping, Laundry, Dietary policies Outbreak Management Antibiotic Stewardship 28 Infection Communication How are your interdisciplinary team members made aware of infections/outbreaks/isolation precautions Create systems for communication How can you substantiate your system is effective 29 Monitoring for Signs/Symptoms of Infection Are staff trained on signs and symptoms of infection Are staff trained to pick-up on subtle change in condition (i.e., mental status change, falls, acute functional decline) Are there systems for monitoring and reporting of s/sx of infection 30 10

11 Definition of Fever 1. A single oral temperature greater than 37.8C (100F) or 2. Repeated oral temperatures greater than 37.2C (99F) or rectal temperatures greater than 37.5C (99.5F) or 3. A single temperature greater than 1.1C (2F) over baseline 4. Lower febrile response in the elderly McGeers Outbreak Management 32 Outbreak Control Surveillance data or daily resident monitoring systems should be used to detect and prevent outbreaks in the facility Outbreak o Defined as 3 or more residents with like symptoms o Example: 3 residents with N/V 33 11

12 Outbreak Management Trends that are 10 % higher than the historical rate of infection for the facility that may reflect an outbreak or seasonal variation and therefore warrant further investigation.. Or 1 occurrence of even a single verified case of a highly transmissible disease (Influenza, Scabies, Salmonella, Norovirus) 34 Outbreak Control Prompt notification of NHA, DON, Infection Preventionist (IPCO), Medical Director Implement isolation precautions Assess exposed residents and personnel Training to staff (Use of PPE, hand washing, environmental cleaning, etc..) Investigation of spread 35 Managing the Outbreak Define authority Use pre-existing protocol and plan for dealing with infectious disease endemics Plan should include o Relocation of residents o Confining residents to rooms o Visitor notification and restrictions o Obtain cultures o Isolate o Administration of prophylaxis or treatment 36 12

13 Management of Environment Increase the frequency of routine environmental cleaning including bathrooms and around the resident s living space Particular attention should be given to cleaning objects that are frequently touched such as faucets, door handles, light switches and bed rails Housekeeping policies and procedures 37 Preventing Spread of Infection F441 When the infection control program determines that a resident needs isolation the facility must isolate the resident Prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease 38 Preventing Spread of Infection Staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Linens: Personnel must handle, store, process and transport linens so as to prevent the spread of infection 39 13

14 Common Outbreaks 40 Influenza Outbreak Management Vaccination should be provided and strongly encouraged to all residents and staff What is your process? Who ensures securing from CDC the most current Vaccine Information Sheet (VIC)? Ensuring ALL residents/families and staff receive education prior to administration Medical Director Standing Protocols? New Admissions? Checking for contraindications Checking for illness Documentation Observation for side effects 41 Influenza Outbreak Management Testing of suspicious symptoms of respiratory illness during flu season (Oct. 1- March 31) Control of spread (Isolation, limit of daily activities, monitor for ill residents and staff, cohorting) Treatment Antiviral Chemoprophylaxis 42 14

15 CDC Flu Toolkit for Long-Term Care Employers: 43 Gastrointestinal Outbreaks Prevented with Appropriate hand washing Appropriate glove use Proper food handling Proper linen handling 44 Norovirus Outbreak Management Viruses (norovirus specifically) cause most of the outbreaks in LTC Usually transmitted from person-toperson (including residents, staff, visitors and volunteers) Norovirus can persist in the environment and is resistant to many disinfectants Contamination of the environment plays a key role in transmission 45 15

16 Norovirus Outbreak Management Can be severe in the elderly Detected early by recognizing the typical symptoms of illness Can be controlled by promptly implementing aggressive infection control measures to prevent the virus from being transmitted 46 Norovirus Outbreak Management Can be spread hand to mouth Droplets from emesis Can remain in stool for one week Noroviruses are stable in the environment and can survive on inanimate surfaces for up to a week or more Can be spread touch object than mouth 47 Norovirus Outbreak Management Diagnosed by traditional stool cultures (for bacteria) or by examination of stool for ova and parasites Decisions to institute aggressive infection control measures should not be delayed while waiting for results 48 16

17 Norovirus Outbreak Management An outbreak of viral gastroenteritis should be suspected when 2 or more residents and/or staff develop new onset of vomiting and/or diarrhea within 1-2 days 49 GI Virus Outbreak Management Each unit should immediately report any residents or staff with a sudden onset of symptoms suggestive of viral gastroenteritis to the person in-charge and IP/IPCO who should immediately take appropriate action The medical director notified anytime the facility suspects an outbreak 50 GI Virus Outbreak Management New cases should be recorded daily using a line list or worksheet (CDC example) NoroLineList508.pdf Notify the local health department of any suspected or confirmed outbreak Consult with the local health department about laboratory testing Notify any sister facility- if share staff 51 17

18 GI Virus Outbreak Management Immediate isolation of the resident and restricting access to affected areas is essential Confine symptomatic residents to their rooms until 48 hours after symptoms cease Symptomatic residents should be co-horted Exclude non-essential staff from entering room Suspend discharges/transfers to other facilities 52 GI Virus Outbreak Management Require symptomatic staff, visitors and volunteers to stay home until they are symptom-free for at least 48 hours Discontinue "floating" staff from the affected unit to non-affected units, if able Discontinue floating staff from affected units to food service Consider in-room dining 53 GI Virus Outbreak Management Cancel or postpone group activities for at least 48 hours after the last identified case Clean and disinfect all equipment including, but not limited to: B/P cuffs, stethoscopes, electronic thermometers and transfer lifts before using for another resident Dedicate equipment 54 18

19 GI Virus Outbreak Management For residents experiencing vomiting and/or diarrhea: Monitor hydration status I&O monitoring 55 GI Virus Outbreak Management Recommended to limit new admissions until the incidence of new cases has reached 0 least 48 hours If new admissions are being considered, consult with the infection control and the Medical Director Consider admitting to an unaffected unit or to a unit that has no new cases for 48 hours 56 GI Virus Outbreak: Staff Educate staff strict hand hygiene and a clean environment to minimize the risk of transmission of norovirus infection Management staff should conduct surveillance rounds to ensure staff are complying with appropriate IC measures Log should be maintained to record ill staff symptoms and when they returned to work 57 19

20 Surveillance There are no magic buttons 58 Surveillance Cornerstone of IC Program The primary purpose of infection control surveillance is the collection of information for action Use of Tracking Tools Identification of all infections in the facility Detection of types of infections and location in the facility. (Use McGeer Criteria) Determination of prevalence of infections Determine trends Information will assist the facility in the development of an effective Action Plan 60 20

21 Mapping Infections Make sure you are mapping your infections in the building! 61 Documentation and Data Documentation should include written definitions of infections Concurrent surveillance is preferable to retrospective surveillance 62 Process Surveillance Identifies whether the practices are compliant with established prevention, control and policies based on recognized guidelines. Audit- (hand washing, environmental rounds) Do your policies work 63 21

22 Outcome Surveillance Identifies and reports evidence of an infectious disease The outcome surveillance process consists of collecting/documenting data on individual cases and comparing the collected data to standard written definitions (criteria) of infections. (See McGeers Criteria Data- Analysis 64 Infection Rates Calculated monthly, quarterly, & annually Health facility acquired infections (HAIs) HAI rates are calculated as infections per 1000 resident days A standard infection report form facilitates reporting of surveillance information Tables, graphs, and charts may be used and facilitate education of personnel 65 Infection Calculations Infections are counted in the statistics only once. An infection lasting over more than one reporting period reported only once-in the period it had its onset Incidence rated (the number of new cases of infection during a defined time period ) are calculated 66 22

23 Calculation Formula Formula for calculation: Number of new HAI s infections* X 1000 Number of resident days in a month Nosocomial Infections are now known as Healthcare Associated Infection (HAI s) 67 Documentation and Data Documentation should include written definitions of infections Concurrent surveillance is preferable to retrospective surveillance 68 Data Collection Data is collected from Communication with staff Walking rounds Review of MD progress notes Lab/X-ray review Treatment records MAR Nurse notes Information from hospital transfers 69 23

24 Analysis of the Data Includes the following elements on each infection to detect clusters and trends. Resident identifier Type of infection Date of onset Location in the facility Appropriate lab information 70 Antibiotic Review & Stewardship Compare antibiotic with lab C&S report The physician is responsible to review (and prescribe) and we are responsible to communicate results The consultant pharmacist will also review during the medication regimen review and give recommendations as appropriate **Due to the increase in MDRO s, review of antibiotic use is crucial 71 Report Report to the President on Combating Antibiotic Resistance: ult/files/microsites/ostp/pcast/pcast_ carb_report_sept2014.pdf 72 24

25 Report Addresses the history and beginnings of how antibiotics have saved millions of lives The US is at risk of losing progress due to the evolution of antibiotic resistance that was slow at first and we were able to keep up with it, however the document indicates it is now outpacing development of countermeasures President Obama requested the advisors to make practical and actionable recommendations 73 Report Three practical and actionable steps were recommended. Improve surveillance of the rise of antibioticresistant bacteria in order to enable effective response, stop outbreaks and limit spread of antibiotic resistant organisms Increase the longevity of current antibiotics by improving the appropriate use of existing antibiotics thereby preventing the spread of antibiotic-resistant bacteria to basically decrease the rate of antibiotic resistance Increase the rate at which new antibiotics and other interventions are discovered and developed 74 Report Resistance is due largely to extensive exposure of bacteria to antibiotics. One of the recommendations for LTC includes Stewardship programs by the end of 2017, CMS should have Federal regulations (Conditions of Participation) in place that will require LTC facilities to develop and implement robust antibiotic stewardship programs that adhere to best practices

26 Report An antibiotic stewardship program will include a system in which the use of antibiotics is only to maximize the benefit to the resident while minimizing the rise in antibiotic resistance and includes: Identification of the microbe responsible for the disease Selection of the appropriate antibiotic including dose, route, duration and d/c when no longer needed 76 Another Good Resource Antibiotic Stewardship Programs in Long-Term Care Facilities Annals of Long-Term Care: /article/antibiotic-stewardshipprograms-long-term-care-facilities 77 Communicable Disease Reporting Iowa Department of Public Health Table of Reportable Communicable and Infectious Diseases Call the 24/7 hotline at mon/pdf/naeyc/ia_reportable_diseases.pdf 78 26

27 Staff Education Orientation and Yearly Policies and Procedures Hand Hygiene (return demonstration) Personal Protective Equipment Transmission Based Precautions Standard Precautions Linen Handling Identification of signs/symptoms of infection Communicating, Documentation, Reporting Staff illness/signs and symptoms Infection Criteria 79 Staff Education On-The-Spot When break in procedures/technique or practice is observed either through audit or observation When an infection (or infections) are identified and procedures/techniques need to be reinforced New information needs to be addressed 80 Audits Hand Hygiene Audits Food Preparation Audits Personal Protective Equipment Audits Water Pass Audits Med Pass Audits Catheter Care Audits Peri-Care Audits Room Sanitization Audits Environmental Audits Dining Room Audits Linen Handling Audits 81 27

28 Well-trained and dedicated employees are the only sustainable source of competitive strength. -Robert Reich 82 References/Resources APIC (Association for Professionals in Infection Control and Epidemiology): State Operations Manual, Appendix PP (F441): Guidance/Guidance/Manuals/download s/som107ap_pp_guidelines_ltcf.pdf 83 Important Resources Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities; Proposed Rule: 16/pdf/ pdf Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria (SHEA/CDC Position Paper):

29 Other Resources Comprehensive Antimicrobial Stewardship Program: oticresistance/asp/ac/acmnasp.pdf Antimicrobial Stewardship Resource Chart: pdf Iowa Department of Public Health: Antibiotic Resistance: 85 Resources CDC: olationprecautions.html _norovirus-toc.html diff_settings.html 86 Questions 87 29

30 Thank You! Sue LaGrange Director of Education Pathway Health 88 30