MDROs and other exciting things What You Need to Know in Long-Term Care

Transcription

1 MDROs and other exciting things What You Need to Know in Long-Term Care 1 April 12, 2018 Toni Foos, RN, BSN, CIC Infection Prevention Manager Colorado Hospital Association

2 Today s Call is Provided by Telligen Telligen: The Medicare Quality Innovation Network (QIN)-Quality Improvement Organization (QIO) for Colorado, Iowa and Illinois QIN-QIO Program Purpose: To improve the efficiency, effectiveness, economy, and quality of services delivered to Medicare beneficiaries 2

3 Today s presentation is based upon CDC recommendations.

4 Next best thing to sliced bread!

5 Multi-drug Resistant Organisms (MDROs) MDROs are microorganisms, predominately bacteria, that are resistant to one or more classes of antibiotics (such as penicillins, cephalosporins and tetracyclines). o Basically --- these are really smart bugs that have learned to outsmart antibiotics!

6 MDROs: What the CDC & WHO are saying It basically shows us that the end of the road isn t very far away for antibiotics that we may be in a situation where we have patients in our intensive care units, or patients getting urinary tract infections for which we do not have antibiotics. Tom Frieden, MD, former CDC Director after a strain of E. coli resistant to Colistin, the last-resort antibiotic, was discovered in the U.S I m sorry, there s nothing I can do for you. The situation is bad and getting worse Last month, an increase in the number of drug-resistant pathogens forced WHO to revise its treatment guidelines for chlamydia, syphilis and gonorrhea. On current trends, a common disease like gonorrhea may become untreatable, and doctors facing patients will have to say, I m sorry, there s nothing I can do for you. Margaret Chan, MD, director-general of World Health Organization, on the growing crisis of drug resistance.

7 CDC Threat Levels

8 Nursing Home Statistics Over the course of a year, up to 70% of nursing home residents receive an antibiotic. Roughly 40-75% of antibiotics are prescribed incorrectly. o High rates of antibiotics are prescribed for UTI and respiratory tract infections. Poor communication between nursing homes hospitals about prescribed antibiotics, plus insufficient infection control practices contribute to antibiotic misuse and spread of antibiotic resistance.

9 How Antibiotic Resistance Happens For example: C diff

10 How Antibiotic Resistance Spreads

11 Clostridium difficile (C. diff / CDI) Bacteria that causes severe watery diarrhea when good bacteria in the gut have been wiped out by antibiotics. 2011: half a million infections in the U.S.; 29,000 die within 30 days of original diagnosis; elderly are most at risk Spores can survive on surfaces for up to 5 months! Fecal-oral spread Spores act like a suit of armor

12 What is Clostridium difficile (C. diff/cdi)? C. diff/cdi video

13 Rationale: Early ID and Containment of CDI Contamination of a resident s skin and environment is greatest when a resident has diarrhea from CDI but hasn t started on appropriate treatment. Rapid containment through implementation of contact precautions for symptomatic residents can reduce contamination (gown and gloves during care of residents with new diarrhea). Assessment Checklist: Do direct care personnel identify and communicate new or worsening diarrhea? Do health care personnel know what precautions are used to prevent the spread of C difficile? Is there a visual tool (e.g. sign) used to communicate to health care personnel and visitors when contact precautions are in use for a resident with known or suspected CDI? Other related assessment checklist topics include hand hygiene, cleaning/disinfection and antibiotic stewardship a.k.a. Advancing Excellence

14 Methicillin-Resistant Staphylococcus aureus (MRSA) Resistant to antibiotics including penicillins such as methicillin and oxacillin. MRSA most often causes skin infections, but may also cause other types of infections including pneumonia and bloodstream and urinary tract infections. Complaint of a spider bite should raise suspicion for a Staph infection. Untreated, a MRSA infection can lead to sepsis (a life-threatening reaction to infection).

15 Extended-Spectrum Beta-Lactamase-Producing Organisms (ESBLs) ESBLs bacteria that produce enzymes capable of breaking down a wide variety of antibiotics, making them ineffective. ESBL-producing bacteria are usually in the family of Enterobacteriaceae (such as E. coli and Klebsiella species). Patients with ESBL infections often have worse outcomes compared to patients with infections caused by non-esbl-producing bacteria.

16 The REALLY Bad MDROs Carbapenem-resistant Enterobacteriaceae (CRE) o Resistant to most antibiotics; occasionally resistant to all antibiotics o Resistance can be due to the production of Klebsiella pneumoniae carbapenemase (KPC) Just like ESBLs, the enzyme breaks down antibiotics, making them ineffective o Outbreaks nationally, and in Colorado Colistin-resistant E. coli o Colistin, the antibiotic of last resort for treating patients with MDROs o 1 st case of colistin-resistant E coli discovered in the U.S. in 2016

17 Infection vs Colonization Both mean there are germs in or on the body... Infection: Resident is sick with signs and symptoms such as fever, pus from a wound, a high white blood cell count, or pneumonia. Colonization: Resident is not sick and has no signs or symptoms.

18 So what must we do to keep our residents, ourselves, and our families safe?

19 Standard Precautions Designed to prevent exposure to or spread of bacteria & viruses to you and your residents Used with everyone, every time Always assume everyone has something infectious Key Components Hand Hygiene Personal Protective Equipment (PPE) Cleaning of Equipment and Environment Sources of Infection Residents Staff Inanimate objects Visitors

20 Hand Hygiene Alcohol Hand Rubs (hand sanitizer) More effective at killing germs than soap and water Apply sufficient amount to cover all surfaces of hands including between fingers. Rub until dry. Do not dry with paper towels. Soap & Water Use when hands are visibly soiled, when alcohol rub has built up, after using the restroom, when caring for patients with diarrhea (e.g. C difficile, etc.). Wash for 20 seconds, or long enough to sing Happy Birthday twice.

21 Create a culture where it is okay to remind each other...

22 Personal Protective Equipment (PPE) When choosing PPE, what part of your body is at risk of exposure? Always remove PPE before leaving resident room or other work environment. No gowns or gloves in the hallway. Remove PPE carefully, so as not to contaminate your clothing or environment Rule of thumb: If it s wet and not yours.. Don t touch it without PPE!

23 Equipment & Environmental Cleaning All equipment used on multiple residents must be cleaned between residents every time (stethoscopes, bp cuffs, etc.) Don t assume someone else cleaned it take responsibility. Always follow manufacturer s instructions for use of cleaning products (don t assume you know, read the label). Contact or Kill time = time needed for disinfection to occur. If you don t follow the instructions, your equipment will not be disinfected. Use a sporicidal (such as professional-grade bleach wipes) for equipment and surfaces in areas where a patient with C diff or other diarrheal illness lives or frequents.

24 Contact Precautions Illness spread by direct or indirect contact o MRSA, VRE, C diff Gown and gloves o Do not save gowns for reuse Remove PPE before leaving room C diff or other diarrheal illness: Wash hands with soap and water; use professional-grade bleach wipes to clean surfaces Masks are worn, per Standard Precautions

25 Droplet vs Airborne Droplet Airborne

26 Droplet Precautions Illness spread by large particle droplets o Influenza, meningitis, pertussis, RSV, mumps Use of a surgical mask Staff remove PPE before leaving room When resident is outside their room, have them wear a mask (as feasible)

27 Airborne Precautions Illness spread by small airborne particles o TB, measles, chickenpox These residents should be in the hospital o Mandatory use of a fit-tested N-95 respirator mask or PAPR o Negative air flow room o Remove mask after exiting room and closing door o When transporting patient outside room, have patient wear a mask

28 Residents on Isolation Things to keep in mind as residents move throughout the home: Practice source containment Clean clothes (no isolation gowns on residents) Resident should perform hand hygiene before leaving room If on droplet precautions, resident should wear a surgical mask when outside their room

29 Influenza Residents 65 & older are at greater risk of serious complications because their immune systems become weakened with age. > 200,000 people are hospitalized each year; > 36,000 deaths Fever, cough, sore throat, muscle aches, headaches, fatigue, runny or stuffy nose Contagious 1 day before symptoms appear and 5-7 days after Spread by droplets from coughing or sneezing (and contaminated surfaces) High-dose vaccine designed for people 65 & older; contains 4 times the amount of antigen as the regular flu shot 29

30 Respiratory Etiquette Educate residents and visitors

31 Sepsis Sepsis is the body s overwhelming and lifethreatening response to infection that can lead to tissue damage, organ failure and death: the body s over-active and toxic response to an infection. Sepsis disproportionately affects older adults... Recent study showed the median age for severe sepsis was 68 years old. 40 percent of survivors suffer long-term cognitive impairment, similar to traumatic brain injury or mild Alzheimer s disease. July 2016 June 2017, 88 percent of all sepsisrelated deaths in Colorado acute-care hospitals were in the population 50 and over. ANY type of infection can lead to sepsis.

32 Maximize Your Resources (Relationships!) Begin to develop relationships with the infection preventionists at the hospitals you partner with. They can be a wealth of information. Hi, my name is. I am the infection preventionist for nursing home (care center, etc.). I just wanted to reach out and introduce myself, as we often share residents and patients back and forth. If you ever have a question about one of our residents, please do not hesitate to reach out. And, if I could get your address, I will send you my contact information. Hopefully, we ll have a chance to meet in person one day. This helps set the stage for communicating in the future!

33 Thank you!

34 Please Contact any of our Quality Innovation Network Representatives to Learn More Lisa Bridwell Nell Griffin Stacy Gordon Gina Anderson Elizabeth Schulte-Mullins Deanna Curry Kristen Ives NHSN support Sarah Wendelboe NHSN support This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.. 11SOW-QIN-QIN-02/09/