IP Programs: Bridging the Gap you are not alone Neil Pascoe RN BSN CIC Epidemiologist Emerging and Infectious Disease Branch Infectious Disease Control Unit IIPW DFW APIC 10/24/13

Today’s Objectives Compare regulatory requirements, standard of care, residents’ rights, oversight, and funding for different practice settings. Discuss the identification of infectious disease, reporting requirements, and infection prevention and control measures. Discuss the issues associated with the transfer of patients among facilities.

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DSHS Regulates Abortion Facilities Ambulatory Surgical Centers Birthing Centers Community Mental Health Centers Comprehensive Out-Patient Rehabilitation Facilities End Stage Renal Disease Facilities Freestanding Emergency Medical Care Facilities Hospitals - General Hospitals - Psychiatric & Crisis Stabilization Units Hospitals - Special Laboratories - (CLIA) Narcotic Treatment Clinics Out-Patient Physical Therapy or Speech Pathology Services Portable X-Ray Services Rural Health Clinics Special Care Facilities Substance Abuse

DADS Regulates one Adult Foster Care Assisted Living Facilities Home and Community-based Services Primary Home Care Hospice Intermediate Care Facilities Nursing Homes Residential Care State Supported Living Centers

DADS Regulates two Area agencies on aging Area agencies on aging transportation Community Attendant Services Community Based Alternatives Community Living Assistance and Support Services Consumer Directed Services Consumer Managed Personal Assistance Services Day Activity and Health Services Deaf Blind with Multiple Disabilities Emergency Response Services Family Care Guardianship Program Home Delivered Meals In-Home and Family Support Local authorities Medically Dependent Children Program Pre-admission Screening and Resident Review Program of All-Inclusive Care for the Elderly Promoting Independence Special Services to Persons with Disabilities Special Services to Persons with Disabilities 24-Hour Shared Attendant Care Texas Home Living

Similarities between DSHS and DADS Both license multiple facility types Both have a regulatory function Both receive state and federal funds to operate Both advocate for healthy Texans

Resident’s Rights People moving into a LTCF become “residents” Resident’s receiving care in a LTC facility are essentially at home

DADS IC Regulatory Enforcement Federal 42 CFR § (F441) – Combines F441, 442, 443, 444 and 445 State 40 TAC Part 1 Chapter 19 subchapter Q – addresses IC requirements Both require facilities to establish and maintain an IC program designed to provide a safe, sanitary, and comfortable environment to prevent the introduction and transmission of disease

Provider Letters SHEA/APIC Recommendations for IC in LTCF vaccines for residents vaccines for HCW DADS TRAINING ng/jointtraining.cfm ng/jointtraining.cfm

Is it bigger than a bread box?

Multi-drug Resistant Organisms: Organizing Your Interventions

Delivery of Healthcare Home Acute Care ASC LTC LTACH How do you maintain quality and continuity of care across settings?

Organizing - Surveillance What is important in your facility? Are certain residents high risk? Documentation new residents status? – Infection or colonization with MDRO Start small and keep it simple Trends over time – run chart Make data available to all staff

Organizing – Bundles, Checklists A “bundle” is a collection of processes (items) needed to effectively care for patients The idea is to bundle together a small number of elements essential to improving clinical outcomes A bundle should be relatively small and straightforward − a set of three to five practices or precautionary steps is ideal A bundle is scored as all or none, no partial credit Pilot’s check list – manage complexity Institute for Healthcare Improvement

Clostridium Difficile Discovered in 1935 by Hall & O’Toole. Ubiquitous anaerobic gram-positive spore forming bacillus. Causes 20-30% of all antibiotic associated diarrhea Named “difficult clostridium” due to its resistance in isolation and growth. In 1978 C. difficile produced toxin was found in patients with antibiotic- associated pseudomembranous colitis. Not all strains toxigenic. Normally found in ~ 3% adults and 15-60% children < 1 yo, 10% to 20% of hospitalized patients Rate and severity of C. difficile-associated diarrhea (CDI) increasing New strain of C.difficile with increased resistance and virulence identified. LaMont, 2006

Prevention Strategies: Core Contact Precautions for duration of diarrhea Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and environment Laboratory-based alert system for immediate notification of positive test results Educate about CDI: HCP, housekeeping, administration, patients, families Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.

Prevention Strategies: Supplemental Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)* Presumptive isolation for symptomatic patients pending confirmation of CDI Evaluate and optimize testing for CDI Implement soap and water for hand hygiene before exiting room of a patient with CDI Implement universal glove use on units with high CDI rates* Use sodium hypochlorite (bleach) – containing agents for environmental cleaning Implement an antimicrobial stewardship program * Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

Rationale for considering extending isolation beyond duration of diarrhea Bobulsky et al. Clin Infect Dis 2008;46:

Outline of a C. difficile “Bundle of Bundles” Prompt identification and isolation of cases – at first suspicion Laboratory testing Hand hygiene Environmental cleaning Antimicrobial stewardship Surveillance Visitors ???

LTCF and Reporting HAI Texas Healthcare-associated Infection and Preventable Adverse Event Reporting

NHSN (National Healthcare Safety Network) see packet material Voluntary, secure, internet-based surveillance system Integrates patient and healthcare personnel safety surveillance systems Managed by the Division of Healthcare Quality Promotion (DHQP) at CDC. Open to all types of healthcare facilities in the United States, including acute care hospitals, long term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers, and long term care facilities.

31 View reports & comment CMS HAI Reporting

Significance of Multi-Drug Resistant Microorganisms

MDRO definition MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents Although the names of certain MDROs describe resistance to only one agent (e.g., MRSA, VISA/VRSA, PRSP) extended spectrum beta-lactamases (ESBLs) and others that are resistant to multiple classes of antimicrobial agents, are of particular concern In addition to Escherichia coli and Klebsiella pneumoniae intrinsically resistant to the broadest-spectrum antimicrobial agents – Fairly common to the Gram negative bacteria – Acinetobacter baumannii resistant to all antimicrobial agents, or all except imipenem – Stenotrophomonas maltophilia - Burkholderia cepacia -Ralstonia pickettii

CRE invades U.S. health care facilities

35 Spread of Carbapenemase Producers

Carbapenem-resistant Enterobacteriaceae (CRE)  Common cause of HAIs  Found in both acute care hospitals and long-term care settings  Since 2004, reports of CRE cases from LTACH and LTCF  Similar to the spread of other MDROs  Movement of colonized patients across the continuum of care contributes to regional transmission  Supported by mathematical modeling Urban C et al. Clin Infect Dis 2008;46:e Endimiani A et al. J Antimicrob Chemother 2009;64: Smith DL et al. PNAS 2004;101:

Inter-Facility Transmission of MDROs (Including CRE) Munoz-Price SL. Clin Infect Dis 2009;49:

Healthcare Community KPC outbreak, Chicago 2008 Clin Infect Dis 2011;53:

Urine Culture Result 39

Important Concepts for MDRO Transmission Once introduced, transmission and persistence depend on: – availability of vulnerable patients – selective pressure exerted by AMR use – >potential for transmission with > numbers of colonized or infected patients ("colonization pressure") – impact of implementation and adherence to prevention efforts.

Important Concepts for MDRO Transmission 2 Patients vulnerable to colonization and infection include – severe disease – compromised host defenses from underlying medical conditions – recent surgery – or indwelling medical devices (e.g., urinary catheters, central lines, or endotracheal tubes – Hospitalized- esp. in ICU

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Epidemiologically Important  Common cause of infection  Multidrug-resistant, limited treatment options  Capable of transferring resistance  High mortality rates for invasive infections  Potential to spread out of healthcare settings

What Can Healthcare Professionals Do? Know if patients in your facility have CRE. Request immediate alerts when the lab identifies CRE. Alert the receiving facility when a patient with CRE transfers out, and find out when a patient with CRE transfers into your facility. Protect your patients from CRE. Follow contact precautions and hand hygiene recommendations when treating patients with CRE.

What Can Healthcare Professionals Do? Dedicate rooms, staff, and equipment to patients with CRE. Prescribe antibiotics wisely (Get Smart for Healthcare). Remove temporary medical devices such as catheters and ventilators from patients as soon as possible. Report cases promptly Communicate!

See Handout

Disclosure of PHI

Texas MDRO Reporting  CDC Tool Kit (  CRE E. coli, Klebsiella species, MDR Acinetobacter Voluntary 2013 Mandatory likely 2 nd Q DSHS lab capacity  All sites to be reported  No isolate submission mandated  NHSN case definitions

Surveillance Definitions Facilities/Regions should have an awareness of the prevalence of CRE in their Facility and Community Focus on Klebsiella species, E. coli and MDR Acinetobacter CDC CRE surveillance definition (2012 breakpoints) Nonsusceptible to one of the carbapenems: doripenem, meropenem, or imipenem AND Resistant to all 3 rd generation cephalosporins tested (Some Enterobacteriaceae are intrinsically resistant to imipenem e.g. Morganella, Providencia, Proteus)

The Burning Platform

Why We Need to Improve Antibiotic Use Antibiotics are often over- or misused in hospitals Antibiotic misuse adversely impacts patients and society by driving the development of resistance. Antibiotics are the only drugs where use in one patient can impact the effectiveness in another. Optimizing antibiotic use improves patient outcomes and reduces wasting these vital drugs Improving antibiotic use is a public health imperative

So What Can We Do? Given the increasing numbers of MDROs and the sparse number of new antibiotics, we need to “get back to basics”. Give fewer antibiotics (“de-escalate” from broad spectrum combinations) and treat for fewer total days. Don’t treat viral illnesses with antibiotics. Don’t treat colonization –wounds, trach tube, Foley. Remove foreign bodies e.g. CVPs, Foleys if possible Use maximum barrier precautions HAND HYGIENE BETWEEN ALL PATIENTS

Optimize selection, dose and duration of Rx for improved patient outcomes Prevent or slow the emergence of antimicrobial resistance Reduce adverse drug events including secondary infection (e.g. C. difficile infection) Reduce morbidity and mortality Reduce length of stay Reduce health care expenditures Antimicrobial Stewardship Goals MacDougall CM and Polk RE. Clin Micro Rev 2005;18(4): Ohl CA. J. Hosp Med 2011 Jan;6 Suppl 1:S4-15. Dellit TH, et. al. Clin Infect Dis. 2007;44:

Outbreak Reporting  Several Texas laws (Health & Safety Code, Chapters 81, 84, and 87) require specific information regarding notifiable conditions be provided to the Texas Department of State Health Services (DSHS). Health care providers, hospitals, laboratories, schools, and others are required to report patients who are suspected of having a notifiable condition (Chapter 97, Title 25, Texas Administrative Code ). Health & Safety Code, Chapters 81, 84, and 87Chapter 97, Title 25, Texas Administrative Code

Outbreak Reporting

Conclusions – MDRO are associated with significantly increased hospital costs – Investing in state-of-the-art, aggressive infection prevention and antibiotic stewardship programs can result in considerable cost savings – Healthcare Executives should request careful accounting regarding the economic impact of both MDRO and institutional control programs.

DSHS Regulations t.ViewTAC?tac_view=4&ti=25&pt=1&ch=133 t.ViewTAC?tac_view=4&ti=25&pt=1&ch=133 Every Facility type has their own set of rules.

DADS Regulations

Resources ations/handbooks/index.html#handbooks ations/handbooks/index.html#handbooks cp/infectioncontrol/index.html cp/infectioncontrol/index.html tings.html tings.html

Resources continued (McGeer Surv.) (SHEA LTC guide) care/index.html care/index.html