Health Care Associated Infections (HAIs) in LTC

Transcription

1 Watch Out, Incoming: Infections in Long-Term Care Can be Killers for Residents and Staff SHARON THOMAS, BSN, RN Clinical Consultant/Quality Educator MU MDS and Quality Research Team Sinclair School of Nursing QIPMO Health Care Associated Infections (HAIs) in LTC Recent estimates suggest that the rates of HAIs occurring in the NH/SNF population ranges between 1.4 to 5.2 infections per 1000 resident-care days. This means that out of the 1.5 million adults living in NH/SNF 765, million infections will occur every year in the U.S. Eddie Hedrick BS, MT(ASCP), CIC 1

2 F-441 Infection Control Maintains spot on list of 10 most frequently cited deficiencies Usually related to poor handwashing, improper use of gloves, poor peri-care Typical Outbreaks in NH/SNF s Influenza and Streptococcus pneumonia respiratory outbreaks Clostridium difficile and norovirus cause most GI outbreaks MRSA and Gr A Beta Strep are most common cause of skin and soft tissue infection outbreaks UTIs with multi-drug resistant enteric bacteria have recently been identified Outbreaks of disease such as Hepatitis A and B associated with improper injection practices. Eddie Hedrick BS, MT(ASCP), CIC 2

3 Factors Predisposing the Elderly to Infection Impaired Host Defenses Aging of the immune system Chronic disease Medications Malnutrition Anatomic and functional changes Degree of exposure to infections Healthcare-Associated Infections Not present on admission and develop after 48 hours Incidence is greater in elderly that any other age group Not all are preventable Eddie Hedrick BS, MT(ASCP), CIC 3

4 How Are Infections Transmitted? Object to object Bed to stethoscope Person to object Nurse to stethoscope Object to person Stethoscope to resident Person to person Nurse to resident Primary Means of Transmission Vector Vehicle Airborne Contact 4

5 Vectorborne Diseases Transmitted by biting insects and ticks West Nile Lyme Disease Zika Virus Eherlichiosis Yellow Fever Malaria Plague Vehicle Transmission Transmitted through ingestion or injection Blood borne Pathogens Hepatitis B Hepatitis C HIV Arborviruses (West Nile, Lyme, Rocky Mountain Spotted Fever, etc.) Enteric Pathogens Salmonella Shigella 0157 E. Coli Norovirus 5

6 Airborne Transmission Inhaled into lungs or upper respiratory tract Varicella (chicken pox) Measles Tuberculosis Contact Transmission Droplet Flu, common cold Indirect Contaminated devices Direct Skin to skin contact 85% of healthcare-associated infections 6

7 Iceberg Phenomenon What we know is infectious is a small percentage of what is actually infectious. Diseases Frequently Undiagnosed or Which Have a Carrier State HIV Hepatitis B and C Herpes Simplex Salmonella Staph Aureus MRSA, VRE, etc Meningitis C.diff 7

8 Bloodborne Pathogens Hepatitis B and C Easy to transmit HIV Syphilis Universal Precautions Universal precautions have been replaced. Term no longer used. Now we follow Standard Precautions Applies principles of common sense Does not need a diagnosis Becomes a part of routine Health Care Worker behavior Consistent and defendable Eliminates the Uh-Oh factor 8

9 Standard Precautions The minimum infection prevention practices that apply to all patient care regardless of the infection status of the resident. Designed to protect residents and staff Hand hygiene PPE Safe injection practices Safe handling of equipment and environment Respiratory hygiene, cough etiquette Colonization Openings Mouth, nose, vagina, and rectum are always colonized with bacteria capable of causing infection Skin Lesions Are also normally colonized 9

10 Colonized Body Fluids Always colonized Feces Airway secretions Wound drainage Sometimes Blood Urine Internal body fluids Standard Precautions Remember to implement for everyone, not just those you know to be infected. Handwashing Safe sharps handling and disposal PPE Gloves Protective face and eyeware Aprons/gowns 10

11 Handwashing Alcohol-based hand rubs are now considered the primary mode of hand hygiene by the CDC and WHO because of their broad spectrum activity and increased compliance due to less time, less irritation, and availability close to the patient when hands are not visibly soiled or when caring for patient with diarrhea OR second friction rub with soap and water under warm water anytime hands are soiled Handwashing Before touching a resident, even if gloves will be worn Before exiting the resident s care area after touching the resident or immediate environment After contact with blood, body fluids or excretions, or wound dressings Prior to performing aseptic tasks Moving from a contaminated body site to a clean body site during resident care Before donning and after glove removal 11

12 Gloves Wear gloves for: Contact with mucous membranes Contact with non-intact skin Contact with moist body substances or surfaces soiled with them Apron/Gown When it is likely that clothing will become soiled 12

13 Eye and Face Protection When it is likely that eyes or mucous membranes will be splashed by body fluids.???? Do you have proper protection in your soiled utility room? Do you staff use the protection? If not, why not? Transmission-based Isolation 3 types-contact, Droplet, and Airborne Used when routine routes of transmission not completely interrupted using Standard Precautions alone Always in addition to Standard Precautions Efforts must be made to counteract possible adverse events in these residents Balance risk to other residents Potential psychological impact 13

14 Contact Isolation Used for diseases that are known and transmitted through contact MRSA, VRE, MRO, CRE s Precautions include: Wash hands Put on gloves and gown BEFORE entering room Remove BEFORE exiting Wash hands Droplet Precautions Used to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions Use for Pertussis, Influenza, Adenovirus, Rhinovirus, N.meningitis Private room or cohort (separate by at least 3 feet) Wear regular isolation mask for close contact Resident wears mask if transported, if tolerated and follow respiratory hygiene/cough etiquette 14

15 Airborne Transmission Chicken Pox ** Varicella Zoster ** Tuberculosis * Measles ** Use N-95 Respirator For diseases with ** must be properly immunized to enter room. Diseases with * require negative pressure system. STOP Check with nurse before entering Be sure to think Culture Change when you post sign and place isolation carts 15

16 UTI UTI is the second most common infection in the LTC setting. A UTI is the most common cause of hospitalization for a bacterial infection. Chronic asymptomatic bacteriuria is more prevalent that symptomatic bacteriuria. The Urinary System Kidneys Ureters Bladder Urethra Most UTIs are in the lower urinary tract, the bladder and urethra. Women are at greater risk than men. Serious consequences can occur if a UTI spreads to the kidneys. 16

17 Types of UTI Specific Symptoms Parts of urinary tract affected Kidneys (acute pyelonephritis) Bladder (cystitis) Urethra (urethritis) Signs and symptoms Upper back and side (flank) pain High fever Shaking and chills Vomiting Nausea Pelvic pressure Lower abdominal discomfort Frequent, painful urination Blood in urine Burning with urination Discharge UTI Risk Factors Aging disrupts acquired immunity due to T cell dysfunction and blunted Cytokine medicated inflammatory response. Estrogen deficiency causes vaginal prolapse and urinary incontinence promoting ascending flow of bacteria into the urinary tract. Loss of estrogen impairs protective action of colonization of Lactobacillus which suppresses growth of pathogenic bacteria. Benign Prostatic Hyperplasia (BPH) increases the risk of urinary retention. This causes calculi that trap bacteria and cause recurrent UTI. 17

18 When Do You Need a Urine Culture? Urinary symptoms: Frequency Urgency Dysuria Gross Hematuria New onset or worsening of urinary incontinence Suprapubic pain Flank pain Fever New onset delirium When NOT to Check a Urine Culture Isolated leukocytosis on urine dip or urinalysis Odor or change in color of urine After a mechanical fall Fever or new onset delirium with other likely explanations 18

19 Treating the UTI Await culture results unless dysuria or ill. Follow sensitivities of culture results for appropriate antibiotics. Oral and/or IV antibiotic treatment is based on underlying diseases, prior antibiotics, residence, and severity of illness. Also based on category of UTI: Uncomplicated-lower tract, healthy female Complicated-male, urologic abnormality, stones, upper tract Catheter-associated UTI Treat healthy women with lower UTI 3-7 days. Indwelling urinary catheters are more likely to have resistant gramnegatives. Treat ONLY if patient is symptomatic even if culture is positive. McGeer scriteria No Catheter Need 3 Fever or chills New or increased burning pain Indwelling Catheter Need 2 Fever or chills from no other source New flank or suprapubic pain New flank or suprapubic pain Change in character of urine Change in character of urine or gross hematuria or gross hematuria Change in mental Change in mental and/or functional status and/or functional status 19

20 The Doctor Says Charles A. Crecelius, MD, PhD, CMD McGeer criteria revised 2013 to make them more sensitive and specific All UTIs must have symptoms that are new or acutely worse Fever is 2 degrees above baseline or >100 o F or repeated readings >99 o F Worsening mental status can be quantitated Should be acute onset and coupled with inattention, and either disorganized thought or altered level of consciousness. Acute functional decline requires a 4 point change in MDS derived ADLs. The Doctor Says Even with McGeer criteria, diagnosis difficult. Three most important clinical signs are: Dysuria Change in character of urine Change in mental status A positive culture with pertinent clinical symptoms is the gold standard for diagnosing a true infection. 20

21 The Doctor Says With a Foley catheter or ileostomy one of the following strict criteria must be met Fever, rigors, OR new onset hypotension with NO alternate site of infection; Either acute change mental status OR acute functional decline with NO alternative diagnosis AND elevated WBC; New onset suprabubic or CVA pain; Purulent discharge around catheter or acute pain, swelling, tenderness in testes, epididymis, or prostate Definitions Rigors a sudden feeling of cold with shivering accompanied by a rise in temperature, often with copious sweating, especially at the onset or height of a fever. 21

22 Definition CVA Costovertebral angle One of two angles that outline a space over the kidneys. The angle is formed by the lateral and downward curve of the lowest rib and the vertical column of the spine itself. CVA tenderness to percussion is a common finding in pyelonephritis and other infections of the kidney and adjacent structures. Asymptomatic Bacteriuria The definition is Isolation of bacteria in an appropriately collected urine culture from a patient without signs or symptoms of a UTI. Common in patients with indwelling urinary catheters. Do NOT treat in most circumstances. DO NOT obtain urine culture unless symptomatic. DO NOT treat positive urine culture if patient is asymptomatic. DO TREAT prior to urologic intervention and/or neutropenia. 22

23 Catheter Associated UTI (CA UTI) History/exam/labs are all required for diagnosis. New onset or worsening signs/symptoms No other identified source Greater than 10 x 3 cfu/ml colony forming units of bacteria To prevent CAUTI, limit catheter use Incontinence is not an indication for a urinary catheter Remove catheters as soon as possible Use appropriate pre and post insertion practices Change Foley or catheter if positive UTI. Drug Resistant Pathogens Highly resistant organisms associated with LTCFs and LTACHs to include hospitals. The pathogens: ESKAPE pathogens Enterococcus faecium(vancomycin resistant) Staphylococcus aureus (MRSA, VISA, VRSA) Kiebsiellapneumoniae (Extended spectrum betalactamases (ESBL) and CarbapenemResistant Enterobacteriaceae(CRE) Acinetobacter baumannii Pseudomonas aeruginosa Enterobacter species 23

24 Approach to Recurrent UTIs Establish re-infection or relapse (occurs sooner). Gynecologic and urologic evaluation Correct cystoceles (surgery, pessary) Post void residual, urodynamics and cystoscopy as indicated. Behavior changes, i.e., timed voiding. Topical estrogen cream Cranberry may decrease bacteriuria. Antimicrobial prophylaxis occasionally necessary Antibiotic Overuse Failure to differentiate between Asymptomatic Bacteruria and Symptomatic UTI leads to antibiotic overuse. Antibiotic overuse increases adverse events and complications CDI Emergence and transmission of MDROs (Multi-drug resistant organisms) 24

25 Lower Respiratory Tract Infections Bronchitis Pneumonia Respiratory System 25

26 Lower Respiratory Tract Infections Risk factors Previous use of antibiotics Surgery History trach use COPD Advanced age Immunosuppression Unvaccinated LRTIs Declining oral hygiene, difficulty swallowing, and diminished cough reflex especially in those with neurologic conditions increases the risk of aspiration. Also underlying conditions such as COPD and Asthma increase the risk of pneumonia. LRTI attack rate in NH/SNF residents 33/1000 residents vs 1.4/1000 in community. 26

27 Pneumonia Vaccination Two types PCV13 pneumococcal conjugate vaccine PPSV23 pneumococcal polysaccharide vaccine Pneumonia Vaccination The CDC recommends persons 65 and older, receive both. One dose of PCV13 should be administered Adults should receive one lifetime dose PPSV23 should then be administered 6-12 months later Most adults only need one lifetime dose Some, at high risk for infection, may need a second dose in five years A maximum of five doses is recommended 27

28 Influenza in the Elderly Leads all other disease categories in terms of restricted activity and bed delays Elderly consistently have the highest hospitalization and death rates of any population group. Even in mild years here are > than 20,000 excess deaths from flu in the U.S % occur in the elderly. Flu complications pneumonia (viral and Bacterial) and cardiac respiratory failure. Long recovery time in those who do get well. Influenza Largely unnecessary vaccines available since 1960 s Reduces risk or decreases severity Very cost-effective Some anti-virals available for Influenza A viruses Discuss use of anti-virals with your Medical Director. 28

29 Blood-stream Infections Rarely detected in LTCFs Primary: occurs without any infection in other sites Secondary: the presence of infection in a site such as urinary tract, or LRI can lead to a blood stream infection with the same organism As acuity of illness in LTC residents has increased so has the use of intravascular devices More than 250,000 central line-associated BSIs in U.S. yearly Pittet et al. JAMA 1994; Kievens et al. Public Health Reports Skin and Soft-Tissue Infections Decubitus Ulcers Occurs in 20% of LTCF residents and are associated with increased mortality. (osteomyelitis, bacteremia = 50% mortality) Risk factors immobility, pressure, friction, sheer, moisture, malnutrition, steroids, infection, reduced nursing time. Prevention = nutrition, preventing fecal incontinence, plan for turning, eliminating focal pressure, keeping dry skin. 29

30 Gastro-Intestinal Infections Viral gastroenteritis (rotavirus, enterovirus, or norovirus), Bacterial gastroenteritis (E.coli, Campylobacter, Salmonella, Shigella) Clostridium difficile is becoming number 1 cause of diarrhea in NH/SNF residents Clostridium difficile Colonization vs Infection Colonization: presence of microorganisms without tissue invasion or damage, therefore no signs or symptoms 10-25% hospitalized patients 4-20% LTC residents Infection: presence of microorganisms with tissue invasion and damage, therefore signs and symptoms 30

31 Rapid Rise in Antibiotic Resistance MRSA (Methicillin-resistant Staphylococcus aureus VRE (Vancomycin Resistant Enterococci) CRE (Carbapenemase Resistant) ESBL (Extended Spectrum Beta- Lactamase) Reasons for the Rise Overuse/Misuse (Human and animal) Used when not needed Wrong drug for the bug Wrong dose Improper duration Public perceptions People ask for antibiotics 31

32 Antibiotics in NH/SNFs 40% of systemic drugs prescribed in LTC Odds that a resident will receive a systemic course of antibiotics during one year is 50-70% Studies suggest that 25-75% of systemic antibiotic use may be inappropriate in LTC What Can Be Done? Can not stop microorganisms from becoming resistant But can slow the process down through: Antibiotic stewardship Education Good project for the Medical Director 32

33 Monitoring/Surveillance Collect data Lab, radiology, pharmacy reports Discuss with providers Physical assessment Shift reports Medical records review Interpret the Data Tabulate Collate Consolidate Site Pathogen Location risk 33

34 Report the Data Feedback important Involve the entire team Verbal or written Graphs or tables Know your audience Use current date CMS is Getting Involved Survey and Cert Memo ALL December 23, 2015 Infection Control Pilot Project Survey and Cert Memo ALL January 22, 2016 Medicare Learning Network (MLN) Infection Control Courses 34

35 Resources Survey and Cert Memos der-enrollment-and- Certification/SUrveyCertificationGenInf o/policy-and-memos-to-states-and- Regions.html Resources Infection Control in LTC Website: infection-control.aspx ettings.html CDC site with toolkit Hand Hygiene in Healthcare Settings CDC s 35

36 Resources omes/pdf/infection_control_guidelines.pdf QIPMO Thank you! 36