1. Infection Prevention & Control In Post- Acute Care
Dolly Greene RN, CIC
Director Clinical Services & Education
Diagnostic Laboratories & Radiology

2. Disclosure
I have nothing to disclose

3. Objective Review Surveillance methodologies in post-acute care setting
Discuss how to utilize Revised McGeer’s Criteria
Discuss how to document and evaluate possible infection events
Review management of residents with MDROs and how to appropriately utilize transmission-based isolation systems

4. CMS Interpretive Guidelines
§ 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
§ (a) Infection Control Program
The facility must establish an Infection Control Program under which it—
(1) Investigates, controls, and prevents infections in the facility;
(2) Decides what procedures, such as isolation, should be applied to an individual resident; and
(3) Maintains a record of incidents and corrective actions related to infections

5. Surveillance
Defined as: Ongoing, systematic collection of data, analysis and interpretation of data which is essential to the planning, implementation and evaluation of public health practices.
Surveillance process is closely integrated with the timely dissemination of data collected to those who need to know!

6. Surveillance Process for data collection:
Observe, assess, and document residents with signs & symptoms of possible infection
Analyze documented data
Observation of infection control practices of staff
Document regular audits of staff practices
Determine interventions needed
In-service
Document interventions
Evaluate interventions with follow-up
The surveillance process is an integral component of your infection prevention and control program. This process includes the collection of data while observing, assessing and then documenting findings of resident’s signs and symptoms of what could possibly be a true infection. Once this is done the IP should analyze the data collected and documentd and decide if it truly is considered an infection according to the definitions of infection in LTC. This data allows the IP to know what areas and possibly which HCW to observe for IC practices. This too needs to be documented. Then the IP determines what interventions can be implemented to curtail any problem that may passed from resident to resident . In-servicing is vital in this surveillance process. Follow-up is essential to know if the interventions are sustainable and effective.

7. Why Do Surveillance? Monitor for trends Take immediate action
To develop a measure for learning about course of disease & risk groups
Guide the planning of interventions
Evaluate effectiveness of interventions
Protect residents and staff
For Quality Improvement of nursing care
The goal of a surveillance program is to detect problems early on so control strategies can be implemented early in the process possibly avoiding an outbreak. Surveillance provides information to guide us in our education programs for continuous improvement of resident care.

8. Basic Concepts
Understanding these concepts is essential to conducting a meaningful surveillance program
Infection vs. Colonization
HAI vs. community-acquired infection (CAI)

9. INFECTION VS. COLONIZATION
Presence of pathogen on culture Organism growth & invasion of host Presence of clinical signs & symptoms
Presence of microorganism on culture
No tissue invasion
Absence of clinical signs & symptoms
Next we need to be able to distinguish between these 2 conditions and terms
So let us clarify what we mean when we say “colonized” vs “infection”

10. Does It Meet The Criteria?
Determine if the symptoms manifested by your resident meets the McGeer’s definitions of infection
This provides consistency to each case evaluation and valid comparisons.
Once you have ruled out Community Acquired Infection, your next 2 choices are HAI or possibly “does not meet the criteria”. The Critetia that we currently use in LTC is the McGeer’s criteriia

11. Revised McGeer’s Criteria* (RMC)
Definition of what is considered to be an infection
Residents who clinically manifest specific symptoms
Consistent criteria to be used for valid comparison
Compare the collected, documented S/S of each resident with the criteria from RMC to the appropriate site of suspected infection
These are the criteria/definitions considered to be the standard of practice in long-term care.
Surveillance tool not a diagnostic tool!
*Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria. October SHEA/CDC Position Paper.
McGeer’s criteria were first introduced in Recently these criteria have been revised (2012) and theses new criteria are due to be published in the Sept 2012 Journal of ICHE. REVIEW A FEW CRITERIA such as UTI with and without a catheter
These criteria are not to be used to determine if the doctor should be notified or not of a change of condition. When there is a change, the doctor should be notified. This is also not used for diagnostic purposes either. This is a Surveillance tool not a diagnostic tool.

12. Which Infections Should Have Priority
According to revised McGeer’s Criteria the infections that should have priority are:
Those shown to be avoidable
Those that cause significant morbidity and mortality
Those with evidence of transmissability in HC setting
Those caused by pathogens causing serious outbreaks
In tracking infections the ones that we look at with a sense of priority are those that can be avoided, those that have the ability to cause residents to die or be very sick, those that can be transmitted to other residents, and those infections that can cause serious outbreaks to occur because of them.

13. Changes to McGeer’s (1)
New definition for HAI (timeframe) vs Community Acquired Infection (2 calendar days instead of 72 hours)
More detailed criteria for UTI
Without F/C--confusion is not a criteria!
With F/C acute change in mental status IS a criteria.
New Language: Constitutional Criteria (fever, leukocytosis, acute mental confusion, acute functional decline)
Now lets talk about some of the changes you will find in the new definitions

14. Changes to McGeer’s (2) Definition of fever 100F or
Repeated oral temps of 99F or repeated rectal temps of 99.5F or
2 degrees above baseline temperature for pt.
Definition of Influenza-no longer seasonal
More thorough definition of Mental Confusion and functional decline
New Category for CDI & Norovirus

15. Mental Confusion Assessment
Must be an ACUTE change & ACUTE onset
Fluctuating behavior- coming & going during assessment period
Inattention-Cannot keep track of discussion, difficulty focusing attention AND either:
Disorganized thinking-Incoherent, rambling, unclear flow of ideas OR
Altered level of consciousness-level of consciousness different from baseline
ALL CRITERIA MUST BE MET!

16. Acute Functional Decline
Decline considered when resident has a 3-point increase in total ADL items each scored from 0 (independent) to 4 (total dependent. ADLs are:
Bed mobility
Transfer
Locomotion within facility
Dressing
Toilet use
Personal Hygiene
Eating
Acute functional decline is part of the constitutional criteria. If you see changes in a residents functional ability such as mentioned on this slide this can qualify as one of the constitutional criteria changes. You either need a 3pt increase in one of these ADLs, which would mean a dramatic change, or you can see subtle changes in 3 of these ADLs by just one point and that would also qualify as acute functional decline.

17. Respiratory Tract
Four Categories of respiratory infections with varying criteria:
Common cold syndrome/Pharyngitis
Influenza-like illness
Pneumonia
Lower Respiratory tract (bronchitis or tracheo- bronchitis)
Here are the four categories for Respiratory tract infection events. In the first category common cold/pharyngitis—there are no changes from the old criteria. Two symptoms are still required

18. Common Cold Syndrome (or Pharyngitis)
At least 2 criteria must be present
Runny nose or sneezing
Stuffy nose (i.e., congestion)
Sore throat or hoarseness or difficulty in swallowing
Dry cough
Swollen or tender glands in the neck (cervical lymphadenopathy)

19. Pneumonia All criteria 1-3 must be present:
1. Interpretation of Chest Xray as demonstrating pneumonia or presence of NEW infiltrate.
2. At least one of the following respiratory sub-criteria (a-f):
a. New or increased cough
b. New or increased sputum production
c. O2 saturation<94% on room air or a reduction in O2 saturation of more than 3% from baseline
d. New or changed lung exam abnormalities
e. Pleuritic chest pain
f. Respiratory rate of >/=25/minute
3. At least one constitutional criteria (fever, leukocytosis, chg in mental status or functional decline)

20. Lower Respiratory Tract
All criteria 1-3 must be present:
1. Chest xray not performed or, negative for pneumonia or new infiltrate
2. At least 2 of the respiratory symptoms from the pneumonia category of infection symptoms
3. At least one constitutional criteria (fever,
leukocytosis, acute change in mental or functional status)
Rule out CHF or other lung diseases which could mimic a respiratory infections due to similar symptoms

21. Influenza-like Illness
Both criteria 1 and 2 must be present
1. Fever
2. At least 3 of the following sub-criteria symptoms must be present
Chills
New headache or eye pain
Myalgias or body aches
Malaise or loss of appetite
Sore throat
New or increased dry cough
Here there has been a slight change. It now does not required the infection to be during what is normally considered flu season. Since 2009 when the H1N1 Influenza was circulating, we found there is not necessarily a season for flu—it can happen any time of year. So that one stipulation has been removed (season)

22. New Criteria for UTI without Indwelling Catheter (1)
Both criteria 1 and 2 must be present:
1. At least one of the following signs/symptoms sub criteria (a- c)present:
(a) Acute dysuria or acute pain, swelling or tenderness of the testes, epididymis or prostate
(b) Fever or leukocytosis and
At least one of the following localizing urinary tract sub-critetia:
Acute costovertebral angle pain or tenderness
Suprapubic pain
Gross hematuria
New or marked increase in incontinence
New or marked increase in urgency or frequency
In this category you will notice some changes from the previous definition. Lets review what is considered meeting the criteria for UTI without an indwelling catheter

23. New Criteria for UTI without Indwelling Catheter (2)
C. In the absence of fever or leukocytosis, then at least two or more of the following localizing urinary tract sub-criteria:
Suprapubic pain
Gross hematuria
New or marked increase in urgency
New or marked increase in frequency
2. One of the following microbiologic sub criteria:
a. >100,000 of no more than 2 species of microorganisms in voided urine
b. >100 colony forming units per ml of any number of organisms in a specimen collected by in and out catheter
Please note that there is no mention of mental confusion or change in mental status in this category of UTI without catheter

24. New Criteria for UTI with Indwelling Catheter
Both Criteria 1 and 2 MUST be present:
1. At least one of the following S/S, sub-criteria (a-d) present:
a. Fever, rigors or new onset of hypotension, with no alternate site of infection
b. Either acute change in mental status OR acute functional decline with no alternate DX AND leukocytosis
c. New onset of suprapubic pain OR flank pain or tenderness
d. Purulent discharge from around the catheter OR acute pain, swelling or tenderness of testes, epididymis or prostate
2. Urinary catheter culture with 100,000 colonies of any organism
Urinary catheter specimen should be collected following replacement of the catheter if the catheter has been in place for more than 2 weeks

25. Definitions for Skin, Soft Tissue and Mucosal Infections
At least one of the following criteria must be present:
1. Pus present at wound, skin, or soft tissue site
2. New or increasing presence of a least four of the following S/S sub-criteria:
Heat at affected site
Redness at affected site
Swelling at affected site
Tenderness OR pain at affected site
Serous drainage at affected site
One constitutional criteria
The criteria for this type of infection category has not changed but it warrants review.

26. Scabies Definition Both criteria 1 and 2 present:
1. Maculopapular and or itching rash
2. At least 1 of the following sub- criteria:
Physician diagnosis
Laboratory confirmation (scraping or biopsy)
Epidemiologic linkage to a case of scabies with laboratory confirmation
So it is important for you to watch that the doctors don’t document Scabies or possible scabies or prophylactic treatment for scabies. I’m sure this is not going to be so easy.

27. Herpes Virus Skin Infections
Herpes Simplex Infection-criteria 1 & 2 must be present:
1. A vesicular rash
2. Either physician diagnosis or laboratory confirmation
Herpes Zoster Infection-criteria 1 & 2 must be present:
2. Either physician diagnosis or laboratory confirmation

28. Conjunctivitis At least one of the following criteria must be present:
1. Pus appearing from one or both eyes, present for at least 24 hours
2. New or increased conjunctival erythema with or without itching
3. New or increased conjunctival pain, present for at least 24 hours
Conjunctival symptoms (“pink eye”) should not be due to allergic reaction or trauma.

29. Gastrointestinal (GI) Tract Infections
At least one of the following criteria must be present:
1. Diarrhea: 3 or more liquid or watery stools above what is normal for the resident within 24 hour period.
2. Vomiting: 2 or more episodes in a 24 hour period.
3. Both of the following S/S sub-criteria:
A. Stool specimen testing positive for a pathogen (i.e., Salmonella, Shigella, Campylobacter sp., rotavirus, or E. Coli 0157:H7
B. AT least one of the following GI sub-criteria:
a. Nausea c. Abdominal pain or cramping
b. Vomiting d. Diarrhea
This is a broad category for GI infections. On the next couple of slides you will see that the McGeer Criteria have etched out 2 separate specific criteria for the two GI infections that we see more often and that is Norovirus and C. diff.

30. Norovirus Gastroenteritis
Both Criteria 1 and 2 must be present:
1At least one of the following GI sub-criteria must be present:
Diarrhea, 3 or more liquid/watery stools above what is normal for resident in 24 hr period.
Vomiting, two or more episodes in a 24 hr. period
2A positive stool specimen for norovirus by either molecular testing (PCR) or EIA or electron microscopy
In absence of lab confirmation, an outbreak (2 or more cases in LTCF) may be assumed to be present if all of the following Kaplan criteria are present:
vomiting in more than half of affected persons
a mean incubation period of hrs
a mean duration of illness of hrs.
no bacterial pathogens is ID’d in stool culture

31. Kaplan’s Criteria for Norovirus
All criteria need to be present, in the absence of laboratory confirmation
Vomiting in more than half of affected persons
A mean incubation period of hours
A mean duration of illness of hours
No bacterial pathogen is detected in stool culture
In the event you do not get the lab confirmation you can compare to the other criteria known as Kaplans criteria for norovirus.

32. Guess What We Have Here?
Can you guess which condition we are going to talk about now?

33. Clostridium Difficile Infection (CDI)
Both criteria 1 and 2 must be present:
1. One of the following sub-criteria present:
Diarrhea (3 or more liquid/watery stools above what is normal for pt. in 24 hr period
Presence of toxic megacolon (abnormal dilatation of large bowel), documented radiologically.
2. One of the following diagnostic sub-criteria present:
Stool sample yields a positive lab test result for CD toxin A or B
Pseudomembranous colitis is identified during endoscopic examination or surgery
This definition of CDI is new to the McGeer’s criteria. Before it was lumped into the GI category of infection.

34. What do you think?
During the annual state survey of facility ABC the surveyor noticed a resident coughing in the hallway. She asked the IP if the resident had a respiratory infection. The IP said, pt. had one 2 weeks ago, MRSA of the respiratory tract. Upon chart review the surveyor saw documentation that the resident had a productive cough and congestion for 4 days now and no notation of the MD being notified. The IP said the patient’s condition did not meet the McGeer’s Criteria therefore she did not call the doctor.
Is this the correct use of McGeer’s Criteria?
This is an actual case that was reported to me a couple of years ago. Tell me what you think about this IP’s understanding of how McGeer’s Criteria are to be used.

35. How are McGeer’s Criteria to Be Used?
Definitions to be used as a tool for assessing each infection event consistently
Not a tool for diagnosis
Not a tool for treatment decisions
McGeer’s criteria is for documentation purposes and valid comparisons.

36. SURVEILLANCE DATA COLLECTION FORM
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Additional Notes:
[ ] Health Associated Infection (HAI) [ ] Community Associated Infection (CAI)
DO NOT FILL OUT THIS PART - FOR INFECTION PREVENTIONIST NURSE USE ONLY
SURVEILLANCE DATA COLLECTION FORM
Resident name: _____________________________________________________ Room#: __________
Date of Admission: _________________________________Date of Onset of Symptoms: ___________
Report Completed By: ___________________________________________________________
Temperature: Pulse: Respirations:
PNEUMONIA
LOWER RESPIRATORY TRACT
(Bronchitis or Tracheobronchitis)
All 3 criteria must be present
1. Interpretation of chest radiograph as demonstrating pneumonia or the presence of new infiltrate
1. Chest radiograph not performed or negative results for pneumonia or new infiltrates
2. At least 1 of the following respiratory sub-criteria
2. At least 2 of the respiratory sub-criteria
a. New or increased Cough
b.New or increased sputum production
b. New or increased sputum production
c. O2 saturation <94% on room air or a reduction in O2 saturation of >3% from baseline
c. O2 saturation <94% on room air or a
reduction in O2 saturation of >3% from baseline
d. New or changed lung examination abnormalities
d. New or changed lung examination
abnormalities
e. Pleuritic chest pain
e. Pleuritic chest pain
f. Respiratory rate of > 25 breaths/min
f. Respiratory rate of > 25 breaths/min
3. At least 1 of the constitutional criteria (see Table 2)
Another version of the forms for a different category. What I suggest is color-coding the forms by site, i.e. blue for respiratory, yellow for urinary, pink for skin, green for GI etc. this may help them when they go to reach for the assessment form.
TREATMENT
Antibiotic Treatment: _______________________________________ Date Started: _______________
Was resident admitted to hospital?: _________________________ Dates: _____________________
Drug / Dosage / Route: ________________________________________________________________
Culture Y / N: ____________ Type: ________________________________________ Date: ________
Results:______________________________________________________________________________
Isolation / Precaution: ______________________ Type: ________________________
DO NOT FILL OUT THIS PART - FOR INFECTION PREVENTIONIST NURSE USE ONLY_________________________________________________________
[ ] Health Associated Infection (HAI) [ ] Community Associated Infection (CAI)

37. INFECTION CONTROL SURVEILLANCE LOG
FACILITY____________________________________
MONTH______________YEAR_________
When the individual forms are filled out and turned in to the IP, the IP should transfer to a log such as this. This helps the IP see if there are trends developing by looking at the columns and when they see too many check marks in one column that should be a flag that something is going on which needs further investigation.

38. Infection Control Surveillance Log
Rm.#
Resident Name
Admit Date
Onset Date
Urine
Respiratory
Skin
Ear/Eye
Blood GI
Other
R/M/P*
I.P.S. (Foley)
Fever
Sign & Symptoms
Mental Status
(Change?)
Organism on
Culture
X-Ray (+/-)
Treatment
CAI
HAI
Does NOT meet Criteria
COMMENT 1A
Pitt, Bradley
6/1
2012
6/3 X FC
Hematuria, pain
50,000 E. coli
Bactrim
Pt arrived evening of 6/1 and SX developed morning of 6/3 2B
Clooney, George
5/2
2011
6/10
100
Cloudy Urine, sl confusion, temp
elevated
50,000 enterococcus
Cipro 5C
Hanks, Thomas
6/11
Cloudy urine --
10,000 E.coli
Macrobid
10A
Sheen, Charles
6/5
Hematuria, headache
100,000 klebsiella p. 3A
Taylor, Elizabeth
1-2
6/22
New cough N
Levoquin
11A
Temple, Shirley
6/24 O
Runny nose, dry cough
Zithromycin 5A
Cruise, Thomas
3/2
3/20
Pus
MRSA
Vancomycin
6/25
99.5
Abd. Pain, foul smelling diarrhea X6
C. diff on toxin test
Vancomycin po 3B
Loren, Sophia
2/12
6/29
Watery diarrhea X4
C.diff
Flagyl
Lets review some possible infection events and lets see how you would qualify these.

39. CALCULATE YOUR RATE OF INFECTION
To calculate the rate of infection gather this information:
# of resident-days (not your average daily census)
# of NEW infections by site
Consider calculating rates by nursing units ( sub-acute vs. custodial care, etc.)
This calculation would be done at the end of the month. That does not mean, of course, that it’s the first time that the surveillance data is looked at, it only means that once the month is completed you can now calculate how well you did in prevention and control strategies.

40. Calculation of Resident-Days
At the end of the month, business office can give you the total number of resident-days.
Resident-days equals the number of beds that were occupied each day of the month.
Example: In a facility of 100 beds (patients), if each of those beds were occupied every day in the month of June (which has 30 days), your total number of resident-days would equal resident-days (100 X 30=3000)

41. CALCULATE Formula to be used:
# of NEW infections X = Number of infections per
# of total resident days resident days
Example: 11 HAI in the month of June at a facility with a total of resident days:
11/4030 X 1000= infections per 1000 resident days
(when using average daily census formula would be 11/134 X 100=8.20%)
Here is the formula to use when calculating your infection rate for the month. Some of you may have used an average daily census at one time, but the current standard of practice is to use the total number of resident days as your denominator. You can see how different the number looks when you report as the number of infections per 1000 resident days!

42. Establish Your Benchmark Infection Rate
Compare your infection rates from the past, to establish your own benchmark.
National or state averages or rates may not reflect the same resident population you have.
Currently there is no relevant national infection rate
NHSN Voluntary reporting for LTCF
Will establish benchmark for Infection rates in LTCF that are meaningful
Based on size of facility
Based on acuity levels
State & national infection averages may NOT be that meaningful to you and your building. Your resident population may not be the same as those in the national or state averages. If you have a high level of acuity, say with subacute patients, you may not look so good if you are compared to facilities with custodial care type residents. Create your own benchmarks by comparing yourself to yourself from previous months.

43. NHSN
National Healthcare Safety Network is a voluntary, secure, internet-based surveillance system. (Part of CDC)
Data entered into NHSN will allow them to gauge progress toward national healthcare associated infection goals.
Data entered by LTCFs will allow for assessment of the impact of efforts to improve IC practices over time.
Monitoring of HH and G & G usage

44. This is an example of a monthly report form
This is an example of a monthly report form. It can also be used as a quarterly report form to submit to your IC Committee meeting. Regardless, whether you use this one or another, a monthly report should be calculated and reported as should a quarterly report. This form allows for both.

45. There are a number of tools that you should utilize to facilitate your tracking and trending and monitoring of what is going on in your facility. This audit for IC practices Form is one that should be used several times throughout the month—making sure you document your observations of all departments of you facility including outsiders like volunteers, visitors, ancillary providers of services to your residents and even the physicians who visit your residents.

46. ANTIMICROBIAL REVIEW “ANTIMICROBIAL STEWARDSHIP”
This can be defined as the appropriate use of antibiotics.
Antibiotics are to be prescribed for infections NOT colonizations
Frequent use of ATB leads to antibiotic resistance
CMS HAS MADE IT THE RESPONSIBILITY OF THE IP TO MONITOR THE PHYSICIAN’S PRESCRIBING PATTERNS*.
IP must be monitoring the use of antibiotics in the facility each month (part of surveillance process)
*2009 CMS “Interpretive Guidelines for Long-Term Care Facilities”, Tag F441.
You may believe or think this is the job of the physician, but CMS has made this your responsibility –you need to monitor the way the doctors are ordering and using the antimicrobials. If you feel there are orders that are not appropriate consult with your medical director. He may be able to reach out to other physicians who admit patients to your facility. Later today you will hear an in-depth presentation on this topic by Dr. Kavita Trivedi from CDPH.

47. ANTIBIOGRAM Also referred to as SUSCEPTIBILITY report
Used to track the changing sensitivity pattern of the bacteria that exist in a facility
Can be used by physicians to guide prescribing decisions regarding appropriate empiric antimicrobial treatment choices when susceptibility report not yet available
Can be used to assess changes in multidrug resistance of significant pathogens
However, as good as the susceptibility report is it is not a definitive test because organisms can turn their resistance on and off.
It is good for a first look and if the doctor does not want to wait for the results of the C&S to use the antibiogram for empiric therapy. This too should be reviewed and discussed with your antimicrobial review committee at your quarterly QA meetings. It would be wonderful if this information could be shared with all licensed nurses and all the physicians who have patients in your facility.

48. Monthly culture (i.e., UA & C&S) Baseline culture Screening culture
Routine Cultures
NOT RECOMMENDED
Monthly culture (i.e., UA & C&S)
Baseline culture
Screening culture
Clearance culture
Cultures should only be done on clinically sick patients
Do not go on a fishing expedition because you will definitely “CATCH FISH”
If you do and you get positive findings what does the doctor do with this information (order antibiotics again?)

49. Diagnosing Infections
Diagnosing infection is a clinical skill, NOT a microbiological technique!
Always try to remember this: clinical trumps microbiological.
The cultures are supportive data not THE most important information in determining infection(not the most important piece to the puzzle)

50. Case Study
Mrs. Jones was admitted to ABC skilled nursing facility with a DX of S/P UTI. On admission the attending doctor ordered a repeat UA C&S after completion of ATBs. The order was followed and the results revealed 50,000 colonies of ESBL in the urine. When the physician was notified of the C&S results he placed Mrs. Jones on Imipenem. The DON informed the physician that the resident had no symptoms of an infection, but the doctor stated he still wanted the ATB given, and added “the surveyors would expect the patient to be treated!” The resident was then placed on Isolation.
What do you think about these orders given?
Let’s discuss the problems in this case scenario

51. High Level of Suspicion
Early identification
Early interventions
Better outcomes
Maintain a high level of suspicion at all times. This will allow for earlier detection interventions which will then result in better outcomes. Train your staff to have this high level of awareness also and report anything they suspect!
Tell story of Dad with TB diagnosis

52. Take Home Points! Get organized
Assess surveillance tools (forms) for monitoring and documentation
Use Revised McGeer’s Criteria (your bible!)
Observe and audit staff frequently for Infection Prevention & Control Practices (HH, Isolation practices with G & G use)
Give feedback of audits to HCWs and IC Committee
Education (on-going)
Monitor antimicrobial utilization (review and share antibiogram with nurses and physicians)
Consider NHSN reporting of HH and G & G use or Lab ID MDRO events

53. REMEMBER!
I want to leave you with this last thought. The most important thing you will do to provide care and protection to your residents is remember to wash your hands when you know it is indicated. In all the studies that have been done they always conclude that HANDWASHING is the cheapest yet the most effective way to prevent the spread of infection and disease. But it only accomplishes this when it is done at the times that are necessary!

54. RESOURCES
APIC: (Association for Professionals in Infection Control
CDPH: (California Department of Public Health)
CDC: (Centers for Disease Control)
LA County Public Health:
SHEA: (Society for Healthcare Epidemiology of America)
Here are some invaluable websites for you to go to. They can assist you in keeping updated with the current recommendations and guidelines.