EDUCATIONAL SERIES: Navigating Infection Control and Antimicrobial Stewardship in Long-Term Care Webinar #1: Infection Control: Surveillance & Monitoring New England Nursing Home Quality Care Collaborative Webinar Will Begin Shortly. Call-In Number: (888) 895-6448 Access Code: 1228904
Shira Doron, MD Associate Professor of Medicine Tufts University School of Medicine Antimicrobial Steward and Associate Hospital Epidemiologist Tufts Medical Center
Shira Doron, MD Associate Professor of Medicine Division of Geographic Medicine and Infectious Diseases Tufts Medical Center Boston, MA
How confident are you that the infection control policy and practices in your facility are adequate to protect your residents from healthcare-acquired infections? A. I am completely confident that the infection control policy and practices in my facility are adequate B. I am somewhat confident that the infection control policy and practices in my facility are adequate C. I have no confidence that the infection control policy and practices in my facility are adequate
Creating your Institutional Surveillance Plan Understand how to perform a facility risk assessment to guide your plan What is important? What makes sense for your facility? Understand why case definitions are important and how to apply McGeer National Healthcare Safety Network (NHSN) What is NHSN and how can it help? What infection control basics should be addressed in your Surveillance Plan? Useful data collection tools
What should I surveille? Surveil? Survey? What elements should go into my surveillance plan?
Your surveillance plan should be based on your risk assessment Revise annually
Evaluate risks with input from infection prevention, medical, and nursing staff, leadership and others Determine priorities based on the identified risks for acquiring and transmitting infections Develop goals to minimize infection transmission Develop, implement and monitor measures to achieve specific goals
Published or evidence-based surveillance criteria (NHSN LTC definitions, McGeer criteria) Data collection tool At least quarterly updates to QAA Follow-up activity in response to surveillance data (e.g. outbreaks) Annual summary of surveillance data
Stone, Nimalie D. et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infection control and hospital epidemiology:33.10 (2012): 965 977.
NHSN McGeer Originally published in 1991, expert opinion Only applicable to elderly institutionalized adults Updated in 2012 to be in line with more recent diagnostic technology and existing NHSN definitions, and can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc35 38836/
Table 1. Constitutional Criteria for Infection Fever Leukocytosis Acute Mental Status Change Acute Functional Decline Single oral temp >37.8 ⁰C (100 ⁰F), OR Repeated oral temp >37.2 ⁰C (99 ⁰F), OR Repeated rectal temp >37.5 ⁰C (99.5 ⁰F), OR Single temp >1.1 ⁰C (2 ⁰F) from baseline from any site >14,000 WBC / mm 3, OR >6% band, OR 1,500 bands / mm 3 Acute onset, AND Fluctuating course, AND Inattention, AND Either disorganized thinking, OR altered level of consciousness 3-point increase in baseline ADL score according to the following items: 1. Bed mobility 2. Transfer 3. Locomotion within LTCF 4. Dressing 5. Toilet use 6. Personal hygiene 7. Eating [Each scored from 0 (independent) to 4 (total dependence)]
Table 3. Respiratory Tract Infection (RTI) Surveillance Definitions Syndrome Criteria Selected Comments* Common cold syndrome or pharyngitis Must fulfill at least 2 criteria. Runny nose or sneezing Stuffy nose or nasal congestion Sore throat, hoarseness, or difficulty in swallowing Dry cough Swollen or tender glands in the neck (cervical lymphadenopathy) Fever may or may not be present Symptoms must be new and not attributable to allergies Influenza-like illness Must fulfill both 1 AND 2. 1. Fever 2. At least three of the following criteria Chills New headache or eye pain Myalgias or body aches Malaise or loss of appetite Sore throat New or increased dry cough If both criteria for influenza-like illness and another upper or lower RTI are met, only record diagnosis of influenza-like illness RTI criteria met RTI criteria NOT met
Table 3. Respiratory Tract Infection (RTI) Surveillance Definitions Syndrome Criteria Selected Comments* Pneumonia Must fulfill 1, 2, AND 3. 1. Chest X-ray with pneumonia or a new infiltrate Conditions mimicking the presentation of RTI (e.g., congestive heart failure or interstitial lung diseases) should be excluded 2. At least one of the following criteria New or increased cough New or increased sputum production O 2 sat <94% on room air, or >3% decrease from baseline O 2 sat New or changed lung exam abnormalities Pleuritic chest pain Respiratory rate 25 breaths/min 3. At least one of the following criteria Fever Leukocytosis Acute mental status change Acute functional decline RTI criteria met RTI criteria NOT met
Table 3. Respiratory Tract Infection (RTI) Surveillance Definitions Syndrome Criteria Selected Comments* Bronchitis or Tracheobronchitis Must fulfill 1, 2, AND 3. 1. Chest X-ray not performed, or negative for pneumonia or a new infiltrate Conditions mimicking the presentation of RTI (e.g., congestive heart failure or interstitial lung diseases) should be excluded 2. At least two of the following criteria New or increased cough New or increased sputum production O 2 sat <94% on room air, or >3% decrease from baseline O 2 sat New or changed lung exam abnormalities Pleuritic chest pain Respiratory rate >25 breaths/min 3. At least one of the following criteria Fever Leukocytosis Acute mental status change Acute functional decline RTI criteria met RTI criteria NOT met
Table 2. Urinary Tract Infection (UTI) Surveillance Definitions Syndrome Criteria Selected Comments* UTI without indwelling catheter Must fulfill both 1 AND 2. 1. At least one of the following sign or symptom Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and 1 of the following: Acute costovertebral angle pain or tenderness Suprapubic pain Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency If no fever or leukocytosis, then 2 of the following: Suprapubic pain Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency 2. At least one of the following microbiologic criteria 10 5 cfu/ml of no more than 2 species of organisms in a voided urine sample 10 2 cfu/ml of any organism(s) in a specimen collected by an in-and-out catheter The following 2 comments apply to both UTI with or without catheter: UTI can be diagnosed without localizing symptoms if a blood isolate is the same as the organism isolated from urine and there is no alternate site of infection In the absence of a clear alternate source of infection, fever or rigors with a positive urine culture result in the non-catheterized resident or acute confusion in the catheterized resident will often be treated as UTI. However, evidence suggests that most of these episodes are likely not due to infection of a urinary source. Urine specimens for culture should be processed as soon as possible, preferably within 1-2 h If urine specimens cannot be processed within 30 min of collection, they should be refrigerated and used for culture within 24 h UTI criteria met UTI criteria NOT met
Table 2. Urinary Tract Infection (UTI) Surveillance Definitions Syndrome Criteria Selected Comments* UTI with indwelling catheter Must fulfill both 1 AND 2. 1. At least one of the following sign or symptom Fever, rigors, or new-onset hypotension, with no alternate site of infection Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis New-onset suprapubic pain or costovertebral angle pain or tenderness Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate 2. Urinary catheter specimen culture with 10 5 cfu/ml of any organism(s) Recent catheter trauma, catheter obstruction, or new onset hematuria are useful localizing signs that are consistent with UTI but are not necessary for diagnosis Urinary catheter specimens for culture should be collected after replacement of the catheter if it has been in place >14 d UTI criteria met UTI criteria NOT met
Table 4. Skin and Soft Tissue Infection (SSTI) Surveillance Definitions Syndrome Criteria Selected Comments* Cellulitis, soft tissue, or wound infection Must fulfill at least 1 criteria. Pus at wound, skin, or soft tissue site At least four of the following new or increasing sign or symptom Heat (warmth) at affected site Redness (erythema) at affected site Swelling at affected site Tenderness or pain at affected site Serous drainage at the affected site At least one of the following Fever Leukocytosis Acute changed in mental status Acute functional decline More than 1 resident with streptococcal skin infection from the same serogroup (e.g., A, B, C, G) may indicate an outbreak Positive superficial wound swab culture is not sufficient evidence to establish a wound infection Scabies Must fulfill both 1 AND 2. 1. Maculopapular and/or itching rash 2. At least one of the following criteria Physician diagnosis Lab confirmation (scraping or biopsy) Epidemiologic linkage to a case of scabies with lab confirmation Must rule out rashes due to skin irritation, allergic reactions, eczema, and other non-infectious skin conditions Epidemiologic linkage refers to geographic proximity, temporal relationship to symptom onset, or evidence of common source of exposure SSTI criteria met SSTI criteria NOT met
Table 4. Skin and Soft Tissue Infection (SSTI) Surveillance Definitions Syndrome Criteria Selected Comments* Oral candidiasis Must fulfill 1 AND 2. 1. Presence of raised white patches on inflamed mucosa or plaques on oral mucosa 2. Medical or dental diagnosis Fungal skin infection Must fulfill 1 AND 2. 1. Characteristic rash or lesions 2. Physician diagnosis or lab confirmation of fungal pathogen from skin scraping or biopsy) Herpes simplex or Herpes zoster infection Must fulfill 1 AND 2. 1. A vesicular rash 2. Physician diagnosis or lab confirmation Reactivation of herpes simplex (cold sore) or herpes zoster (shingles) is not considered a healthcareassociated infection Conjunctivitis Must fulfill at least 1 criteria. Pus from one or both eyes for 24 h New or increased conjunctival erythema +/- itching New or increased conjunctival pain for 24 h Conjunctivitis symptoms (pink eye) should not be due to allergy or trauma SSTI criteria met SSTI criteria NOT met
Table 5. Gastrointestinal Tract Infection (GITI) Surveillance Definitions Syndrome Criteria Selected Comments* Gastroenteritis Must fulfill at least 1 criteria. Diarrhea: 3 liquid or watery stools above what is normal for the resident within 24 h Vomiting: 2 episodes in 24 h Both of the following sign or symptom Stool specimen positive for a pathogen (e.g., Salmonella, Shigella, E coli O157:H7, Campylobacter species, rotavirus) At least one of the following criteria Nausea Vomiting Abdominal pain or tenderness Diarrhea Exclude non-infectious causes of symptoms such as new medications causing diarrhea, nausea, or vomiting or diarrhea resulting from initiation of new enteral feeding Presence of new GI symptoms in a single resident may prompt enhanced surveillance for additional cases In the presence of an outbreak, stool specimens should be sent to confirm the presence of norovirus or other pathogens (e.g., rotavirus, E coli O157:H7) Norovirus gastroenteritis Must fulfill both 1 AND 2. 1. At least one of the following criteria Diarrhea: 3 liquid or watery stools above what is normal for the resident within 24 h Vomiting: 2 episodes in 24 h 2. A stool specimen positive for norovirus detected by electron microscopy, enzyme immunoassay, or molecular diagnostic testing In the absence of lab confirmation, a norovirus gastroenteritis outbreak ( 2 cases in a LTCF) may be assumed if all of the Kaplan Criteria are present o Vomiting in >50% of affected persons o A mean or median incubation period of 24-48 h o A mean or median duration of illness of 12-60 h, and o No bacterial pathogen is identified in stool culture GITI criteria met GITI criteria NOT met
Table 5. Gastrointestinal Tract Infection (GITI) Surveillance Definitions Syndrome Criteria Selected Comments* Clostridium difficile infection Must fulfill 1 AND 2. 1. At least one of the following criteria Diarrhea: 3 liquid or watery stools above what is normal for the resident within 24 h Presence of toxic megacolon (radiologic finding of abnormal large bowel dilatation) 2. At least one of the following diagnostic criteria Stool sample positive for C difficile toxin A or B, or detection of toxin-producing C difficile by culture or PCR in stool sample Pseudomembranous colitis identified in endoscopic exam, surgery, or histopathologic exam of biopsy specimen Individual previously infected with C difficile may continue to be colonized even after symptoms resolve In the setting of an outbreak of GI infection, individuals could be C difficile toxin positive because of ongoing colonization and also be co-infected with another pathogen. Other surveillance criteria should be used to differentiate between infections in this scenario GITI criteria met GITI criteria NOT met
Standardized Surveillance and Infection Tracking
Neither the McGeer criteria nor the NHSN definitions of infection are mean to be used, nor should they be used as criteria for treatment of suspected infection with antibiotics They are intended for standardized surveillance purposes ONLY
CDC s healthcare-associated infection tracking system Collects and feeds back data to facilities, states, regions and the nation Goals: Identify infection prevention problems Benchmark progress of infection prevention efforts Drive progress toward elimination of HAIs
Currently a voluntary pilot project for LTC Expected to become mandatory in the not-too-distant future probably starting with Clostridium difficile Infection (CDI) Events In Massachusetts, currently there are ~90 LTCFs enrolled Community-onset (CO) LabID Event: Date specimen collected 3 calendar days after date of current admission to the facility (specifically, days 1, 2, or 3 of admission) Long-term Care Facility-onset (LO) LabID Event: Date specimen collected > 3 calendar days after date of current admission to the facility (specifically, on or after day 4). DPH to do external validation of the data on 10 nursing homes We strongly encourage facilities that do not currently use NHSN to do so- there is support available to assist you.
Potential future quality measures: MRSA UTI HCP influenza vaccination hand hygiene gown/glove compliance HCP blood/body fluid exposure
Standard precautions hand hygiene, personal protective equipment (PPE), safe injection practices Hand hygiene basics Alcohol based hand rub accessibility (acceptable locations: outside rooms, bedside, pocket, staff work station) Wash when visibly soiled HH even if gloves are used PPE basics Gloves for blood or body fluids, mucous membranes, non-intact skin Clean to dirty or change gloves Gown for uncontained secretions or excretions Facemask within 3 feet if acute illness with cough
Dedicated disposable equipment or disinfect (use the IFUs) POC items (glucometers) Clean and disinfect environment daily Influenza and pneumococcal vaccination (CMS requirement for residents) Staff influenza vaccination No current CMS requirement but DPH requires annual data submission via survey (not NHSN)
Reportable diseases reporting DPH requirement Includes outbreaks and clusters of influenza and norovirus Movement of patients with certain MDROs Communication Between acute care or other providers about infections, antibiotics, culture results Employee health policy compliance (e.g. staying home when sick)
MDPH LTC Infection Control Guidelines C. diff, Pneumococcal disease, GI illness (including Norovirus), Herpes Zoster, Legionella, MDROs, Scabies, TB http://www.mass.gov/eohhs/gov/departments/dph/progra ms/id/epidemiology/providers/infection-control.html CDC Infection Prevention Resources for Nursing Homes CAUTI, C. diff, MRSA, Norovirus, Influenza, CRE https://www.cdc.gov/longtermcare/prevention/index.html
Number of expected infections
Number of actual infections
Standardized infection ratio (risk adjusted)
Default goal is HHS goal of 30% improvement (you can set your own)
Your facility s secret number (unique ID)
Your facility s rank (with 1 being the worst)
Cumulative attributable difference (# of infections needed to avoid to meet goal)
Statistically significant?
After participating in this webinar: (Check all of the following that apply) I feel better prepared to develop my facility surveillance plan for infection control I understand the infection control basics that should be addressed in my facility surveillance plan I want to learn more about using the National Healthcare Safety Network to track CDI in my facility
Facility recognition for program completion Binder "resources Submission of monthly antibiotic starts on the first day of each month (submit for prior month) https://www.surveymonkey.com/r/6bhtj36 Contact for any questions: Melissa Cumming MDPH AR Coordinator 617-983-6800 melissa.cumming@state.ma.us
MARK YOUR CALENDARS! Feb 13 th Introduction to Antimicrobial Stewardship in Long Term Care: What is Antimicrobial Stewardship and Why is it Important? Mar 13 th Apr 3 rd May 8 th Jun 12 th Jul 10 th Aug 14 th Sep 11 th Antimicrobial Stewardship: Strategies for Implementation Infection Control: Prevention Approach to the Patient with Suspected UTI Infection Control: Management (Case Scenarios) Antibiotic Selection, De-Escalation, and Duration How to Get an A on Your Report Card: Prevention and Management of C. difficile and Other Healthcare Associated Infections Measure Your Success: Monitoring and Tracking Data 51
QIN-QIO State Leads Connecticut Florence Johnson fjohnson@qualidigm.org Maine Danielle Watford dwatford@healthcentricadvisors.org Massachusetts Sarah Dereniuk-Dudley sdudley@healthcentricadvisors.org New Hampshire Pam Heckman Pam.heckman@area-N.hcqis.org Rhode Island Nelia Odom nodom@healthcentricadvisors.org Vermont Gail Harbour Gail.Harbour@area-N.hcqis.org This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, 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. CMSQINC22018011295
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