1. The Power of Surveillance
Improving resident outcomes through tracking and preventing infections
Martha Harris, BS, M(ASCP), CIC

2. Learning Objectives
Describe the current and future stresses placed on long-term care facilities (LTCFs) regarding healthcare-associated infections (HAIs)
List the surveillance components of an effective Infection Control Program
Identify common sites for infection in your population
Develop program to collect, review, and report HAI data
Describe various external reporting requirements
Develop resource network

3. State of HAIs in LTCFs
More than 1.5 million residents reside in United States nursing homes. In recent years, the acuity of illness of nursing home residents has increased.
LTCF residents have a risk of developing healthcare-associated infections (HAIs) similar to that seen in acute care hospital patients.
SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility
July 2008

4. HAI Data in LTCFs
In LTCFs, it is estimated that there are 1.6 million to 3.8 million infections occur each year.
The overall infection rate in LTCFs ranges from 1.8 to 13.5 infections per 1,000 resident-care days.
The high number of infection control deficiency citations (F-Tag 441) in NHs highlight the need for a greater focus on infection prevention (AJIC 2011)
There are currently little HAI data and no national surveillance systems for LTCF infections
Estimates have been calculated based on research studies and outbreak reports from the medical literature.
SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility - July 2008
Nursing home deficiency citations for infection control – AJIC – May 2011

5. Future State of LTCFs
The US population aged 65 to 85 years is increasing rapidly, and the population aged 85 years and older is expected to double by 2030.
One of every 4 persons who reaches the age of 65 can be expected to spend part of his or her life in a nursing home; more people occupy nursing home beds than acute care hospital beds in the US.
While there are approximately 80 acute care hospitals in Virginia, there are about 300 nursing homes and nearly 600 assisted living facilities in Virginia.
SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility
July 2008

6. HAI Surveillance in Acute Care Hospitals
1968 – CDC begins acute hospital HAI surveillance on a national level
1970 – National Nosocomial Infection Surveillance system (NNIS)
2005 – National Healthcare Safety Network (NHSN)
2008 – CMS reduced payment for HAI conditions (HACs)

7. HAI Surveillance in LTCFs
Currently, no mandate for reporting of HAIs in LTCFs.
NHSN modules are being developed – but use is totally voluntary at this point in time
When available, using NHSN may be beneficial:
Provide standardization
Make benchmarking possible
Improve quality of data
Help ease the learning curve by starting use early

8. NHSN LTC Module (Draft)
This slide shows a screenshot of a draft of a NHSN urinary tract infection reporting form for long-term care facilities. This form is still in revisions and is not yet accessible on the NHSN website but is available by contacting the VDH HAI Team. The NHSN long-term care module is planned to be released sometime in 2012.
DRAFT

9. LTC Infection Control Program
Designated coordinator
Policy and procedure formation
Surveillance
Education of staff and volunteers in infection control methods
Antibiotic monitoring
Reporting outbreaks and designated diseases to public health
Quality improvement
Environmental review
In the interpretive guidance of the regs, quality improvement and environmental review are not put on the “must have” list.

10. Surveillance Program
Ongoing system for collection of data on infections and antibiotic use in facility
Program should include:
Definitions of HAIs
Characteristics of population at risk
Steady data streams
Microbiology reports
Antibiotic usage reports
Device days

11. Definition of Infection
Active Infection:
A resident with an infection who is culture positive and can exhibit the following symptoms: fever, elevated white blood cell count, inflammation, pus in wound or surgical site, or increased secretions.
Colonization:
A resident who is also culture positive but does not exhibit signs and symptoms of infection. The resident can be a source of transmission of the organism to staff and to other residents, directly or indirectly.

12. McGeer’s Surveillance Criteria
Compiled in 1991
Used primarily for LTC infection surveillance
Published in Am J Infect Control 19(1): 1-7, 1991
No study to determine reliability or validity
No established benchmarks
No risk classifications
CDC is currently working to help update the McGeer criteria and incorporate it into NHSN for LTCFs.

13. McGeer’s Surveillance Criteria
The chart on this slide shows the McGeer surveillance criteria for a few selected types of infections such as respiratory tract/common cold, sinusitis, influenza-like illness, pneumonia, and other lower respiratory tract infections. Symptoms are outlined for each of the infections and comments are included as well when evaluating a patient/resident with these symptoms.

14. Surveillance Definitions
Acute care definitions should not necessarily be used in LTCFs
All symptoms must be new or acutely worse
Chronic symptoms should not be used
Non-infectious causes of signs/symptoms (S/S) should be considered first
Identification of an infection should not be based on one piece of evidence
Physician diagnosis should be accompanied by compatible S/S of infection
While clinical definitions are important for the specific patient for diagnosis and treatment and may be considered somewhat subjective, surveillance definitions are population-based and used very standardized definitions in order to compare like data with like data (apples to apples). Therefore, there may be occasions where a patient may have a clinical definition of a urinary tract infection and is being treated; however, they do not meet the defined UTI surveillance definition. This differentiation should be communicated and understood by clinicians to help avoid confusion and increase the usefulness of surveillance data.

15. Risk of Infection Inherent in the Elderly
There are three basic groups of infection risk factors:
Resident’s physical risk factors
Resident’s psychological risk factors
Device-associated risk factors
Each risk factor contributes to an increased risk of acquiring an HAI for that individual and within the LTC population

16. Most Common HAIs Urinary tract infections Respiratory infections
Catheterization, dehydration
Respiratory infections
Influenza
Skin and soft tissue infections
Ulcers due to lack of mobility, skin breakdown
Gastrointestinal infections
Clostridium difficile, Norovirus
Systematic infections
IV lines or tubes

17. Most Frequent Infections by Facility Type: Virginia
First
Second
Third
Fourth
Fifth
Nursing Home
UTI
90%
Pneumonia
83%
MRSA
77%
CAUTI
71%
SST
66%
Assisted Living Facility
Influenza
35%
33%
Norovirus
26%
19%
The VDH HAI team conducted a needs assessment in assisted living facilities and nursing homes and noted that urinary tract infections (UTIs) are the most frequent infection noted in both assisted living facility settings and in nursing homes.
The chart on the page shows the percentage of responding facilities (nursing homes or assisted living) that indicated a given type of infection was seen frequently or somewhat frequently in their facility. Pneumonia was commonly seen in both types of facilities (2nd most common in nursing homes, 3rd in assisted living), as were skin and soft tissue infections (5th most common in both types). MRSA and catheter-associated urinary tract infections were 3rd and 4th most common in nursing homes. Influenza (2nd) and norovirus (4th) rounded out the top 5 in assisted living facilities.
CAUTI= catheter-associated urinary tract infection UTI= urinary tract infection; not including CAUTI
CLABSI= central line-associated bloodstream infections SST= skin and soft tissue infections
VAP = ventilator-associated pneumonia Pneumonia: not including VAPs
MRSA= methicillin-resistant Staphylococcus aureus 17

18. Data Collection Challenges
Inconsistencies may include:
Application of definitions
Use of microbiological or laboratory tests to support infection diagnosis
Collection of device and patient days
Appropriate documentation of resident’s S/S
Use of one central laboratory
Lack of previous medical history records from other healthcare facilities makes “Present on admission” assessment difficult.

19. Surveillance Data Analysis of data related to resident illness:
Must be systematic and standardized
Will establish facility baselines but are limited to what data are collected
Can identify areas of strength or weakness in the IC program
Raw data can not be used for surveillance reports since they cannot be compared over time.
Raw data refers to simple counts. For example, a facility may have 2 infections in January and 5 infections in February. By only looking at the data, one may jump to the conclusion that February there was a bigger HAI problem. However, without included denominators (such as number of people, resident days, or device days) for that time period in that location, the raw data may be misinterpreted.
Intra-facility (within the facility) customized surveillance may be different than inter-facility (between facilities) standardized surveillance. It is always important to standardize definitions within a facility, but that data may not be comparable to other facilities or to available benchmark data available (such as NHSN). Therefore, it may be important for your facility to use McGeer/NHSN and other standardized definitions to be able to benchmark outside measures.

20. HAI Rates Numerator is the number of HAIs identified
Denominator is the population at risk
Careful: 1,000 is not always the constant
The infection (incidence rate) equals the number of new HAIs divided by the number of resident days multiplied by For example, if there were 8 new cases of influenza in January and there were 980 resident days in January, you would divde 8 by 980 and multiply by 1000 for an influenza rate of 8.16 per 1000 resident days.
Examples provided by Mary Andrus, BA, RN, CIC

21. Incidence Rate
Number of new cases per population in a given time period
Another HAI rate is taking into account the device-associated days. One example would be the incidence rate of residents with a catheter-associated urinary tract infection (CAUTI) per 1000 indwelling catheter days. For example, if there were 2 residents with a CAUTI and 188 indwelling catheter days in the same population during the same time period, you would divide 2 by 188 and multiply by 1000, with an incidence rate of CAUTIs per 1000 indwelling catheter days.
Examples provided by Mary Andrus, BA, RN, CIC

22. Line Listing
This table is an example of a line list. This line list includes the patient number, patient name, patient room number, the source of the culture, the associated organism of the culture if identified, the culture date, any antibiotics if used, and the date.

23. Data Charting
This slide has two tables that show the number of infections by unit and type of infection for two months (January and February). The overall infection rate is calculated for each of the months and units.
Example of the infection prevalence rates for the 4 units in one LTC facility unit for January and February.

24. Run Chart HAI Rate per 1000 resident days Calendar Months
In-services on correct perineal care
URI – residents with productive cough, elevated temperature, or hospitalization captured
HAI Rate per 1000 resident days
A run chart, such as a control chart, is a graph that displays observed data (y-axis) in a time sequence (x-axis) that can be used to help identify problem areas. Run charts are useful in helping identify problem areas by seeing changes in the data that suggest shifts in a process over time or special factors that may be influencing the variability of a process. Typical indicators may be a sudden outlier that is significantly above or below the baseline that is unusually seen, an unusually long run of data points above or below the average line, or along series of consectutive increases or decreases.
In this example, you can see this run chart is showing the HAI rate (y-axis) for each month (x-axis) in the calendar year. Although the HAI rate seems to vary slightly between 3 and 4.7 per 1000 resident days during the first 6 months of the year, it jumped up to 7 in July, which appears that it could be an outlier. In July in-services on perineal care were given. Since July there were consecutive reductions in the HAI rate until the usual baseline variability was re-established.
Calendar Months

25. Using Data to Improve Resident Outcomes
HAI Rate per 1000 resident days
The bar graph on this slide shows the HAI rate per 1,000 resident days by month from January 2008 to November A trend line is included in the graph to allow the reader to easily identify if the rate is increasing or decreasing overall. In this example, the rate is decreasing, but efforts need to be maintained to continue this trend.
Calendar Months for

26. Internal Reporting Share data with internal stakeholders
Administrators, nurses, environmental services, etc.
To help maintain situational awareness and obtain support
To help identify possible challenging areas and possible solutions
To encourage ownership of both the problems and solutions
Data presentation should be customized for the intended audience
Timely, focused data is often preferred
Feel free to add/change.

27. External Reporting
If the HAI occurs within 48 hours or 3 calendar days of admission, report the HAI to the facility the patient/ resident was transferred from
Report infections associated with surgical procedures to the facility where the operation was performed if the HAI occurs within
30 days and there was not an implant
1 year and there was an implant

28. External Reporting
Report any epidemiologically significant infections to your local health department (Examples below. Full list available from HD).
Hepatitis B and C (acute and chronic)
MRSA from sterile site
Pertussis
Foodborne illness
Tuberculosis, active disease
All suspected and/or confirmed outbreaks
Norovirus
Influenza

29. Additional Surveillance
Resident influenza and pneumovax vaccinations
Staff vaccinations and immunization status
Blood and body fluid exposures
Process improvement measures
Hand hygiene
Device utilization ratio
Compliance with personal protective equipment (PPE)
Antimicrobial use
Give examples of device utilization ratio

30. Successful Strategies for Infection Prevention in Assisted Living Facilities and Nursing Homes Toolkit
Available from your local health department.
Full of education on infection prevention and control that you can use TODAY to improve your program.
The picture on this slide is a screenshot of the cover of the toolkit. 30

31. Logs in the Toolkit Monitoring compliance Logs Hand hygiene
Environmental cleaning checklist
Cleaning and disinfection for blood spills or other potentially infectious bodily fluids
Blood glucose monitoring
Logs
Vaccination
Resident immunization record, resident influenza vaccination log, general vaccination log
Illness
Monthly surveillance tracking sheet, gastrointestinal illness log, respiratory illness log, etc.

32. Environmental Cleaning: Measuring Compliance
The image on the slide is a checklist to monitor compliance with cleaning and disinfecting blood spills or other potentially infectious bodily fluids. The checklist is available for use on the VDH HAI website and in the Successful Strategies for Infection Prevention in Assisted Living Facilities and Nursing Homes toolkit.
Environmental Checklist
Environmental Checklist: Blood Spills

33. Individual Immunization Record
This slide has two images – a resident immunization record and a resident influenza vaccination log. Both of these resources are available for use on the VDH HAI website and in the Successful Strategies for Infection Prevention in Assisted Living Facilities and Nursing Homes toolkit.
Resident Immunization Record
Resident Flu Vaccination Log

34. Additional Resources Hospital IPs Local Health Department VDH HAI Team
State organizations
Centers for Disease Control and Prevention:
Clinical guidelines and surveillance definitions
Disease-specific guidance (bloodborne pathogens, norovirus, influenza, TB, MDROs, UTIs)
Environmental cleaning and disinfection
Hand hygiene
Immunizations and employee health
Isolation precautions
Licensure and reporting regulations

35. Use Your Local Resources
Local Hospital IPs
APIC Virginia Members
Local resources may include local hospital infection preventionists, your local health department, APIC-Virginia members, and contacts at other long-term care facilities.
Contacts at other LTC facilities
Local Health Department

36. Use Your Local Resources

37. Summary Surveillance is the best way to know:
What is going on in your facility
What your infection baseline is so you can identify an outbreak more quickly
How well your infection prevention programs are working
What areas you need to provide education for your staff
Public reporting of LTC HAIs is not currently required but may be a part of your future