Long Term Care CDI/MDRO Prevention Collaborative: Connecticut Program Update Richard Melchreit, MD HAI Program Coordinator

National Metrics and 5-Year Targets MetricSource National 5-year Prevention Target On Track to Meet 2013 Targets? Bloodstream infections NHSN50% reductionYes Clostridium difficile (hospitalizations) HCUP30% reductionNo Clostridium difficile infections NHSN30% reductionNo Urinary tract infections NHSN25% reductionNo MRSA invasive infections (population) EIP50% reductionYes MRSA bacteremia (hospital) NHSN25% reductionNo Surgical site infections NHSN25% reductionYes

CMS Reporting Requirements: sorted by year YearHAI EventFacility type/location 2011CLABSIACH/ICUs 2012CAUTIACH/ICUs SSI:COLO, SSI:HYSTACH/all inpatient DEOutpatient Dialysis 2013MRSA bacteremia LabID, CDI LabIDACH/all inpatient HCW vaccinationACH CLABSI, CAUTILTACH/all inpatient CAUTIIRF/adult, pediatric wards 2015CLABSI, CAUTIACH/wards HCW vaccinationACH/outpatient; LTACH, IRF, ASC MRSA bacteremia LabID, CDI LabIDLTACH/all inpatient

CSTE recommendation: CDI reporting (NHSN) to public health departments Organism/ specimen Type of facilityType of location Time frameExceptions C. difficile Infection LabID Event Acute Care Hospitals All inpatientXNICUs, well baby nurseries LTACHAll inpatientX CHAAll inpatientX IRFAll inpatientX Other non IQRAll inpatientX LTCFs*All residentsx * Will require enough facilities to develop the infrastructure and skills necessary to effectively use NHSN.

CSTE recommendation: MRSA Bacteremia reporting (NHSN) to public health departments Organism/ specimen Type of facilityType of location Time frameExceptions* MRSA Bacteremia LabID Event Acute Care Hospitals All inpatientXNone LTACHAll inpatientX CAHAll inpatientX IRFAll inpatientX Other non IQRAll inpatientX LTCFs*All residentsx * Will require enough facilities to develop the infrastructure and skills necessary to effectively use NHSN.

Connecticut State Health Improvement Plan (SHIP) HAI Objectives Benchmark measure Objective #DescriptionBenchmarkGoal 4.27Increase public reporting of HAIsNHSN HAI facility types, locations, events 5% over baseline 4.33Reduce # healthcare associated influenza outbreaks ID Section institutional outbreak database 5% below baseline 4.34Reduce MDRO isolatesCRE, MRSA ABCS5% below baseline 4.29Reduce CAUTIs, CDI LabID Event in Long Term Care Facilities NHSN LTC CAUTI, CDI Lab ID Event 5% below baseline

Overview: Program Challenges Most Challenging HAI C. Difficile (30%) “Other” included lower-respiratory tract infections, non- catheter-associated UTIs, pneumonia Most Challenging IC Aspect Isolation/MDROs (21%) “Other” included cohorting, resident cooperation, transfer data and screening Assessment Survey: Infection Control Policies in Connecticut LTCFs, June 2012

Incidence of MRSA by Place of Onset and Year, Connecticut, p<0.01 a a Chi-square for trend p<0.01 a

Revised Annualized National Estimates, ABCs MRSA (updated Nov, 2012) Revisions include: Adjustment for dialysis; incorporation of interval estimates (not included);enhanced case finding (TN) and resolved data transmission error ( ). Data accessed (frozen) November ~ 27% were outpatient dialysis patients ~ 27% were outpatient dialysis patients ~ 50% were discharged from acute care in previous 3 months ~ 50% were discharged from acute care in previous 3 months

Vancomycin-resistant Enterococci (VRE) Connecticut: VRE Incidence by Hospital Staffed Bed Size VRE Incidence by Age

Percent of CLABSI organisms that were VRE or MRSA:

Emerging Infections Program HAI prevalence survey CT 2011

EIP Antimicrobial Use Survey CT 2011

Carbapenem-resistant Enterobacteriacea Two KPC isolates from CT hospitals confirmed by CDC One NDM NHSN has reporting capability Laboratories report CREs in some other states Laboratory Reportable Condition 2014

Clostridium difficile (CDI) Infections Toolkit Activity C: ELC Prevention Collaboratives Last reviewed - 2/29/ Disclaimer: The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Carolyn Gould, MD MSCR Cliff McDonald, MD, FACP Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

Prevention Strategies Core Strategies –High levels of scientific evidence –Demonstrated feasibility Supplemental Strategies –Some scientific evidence –Variable levels of feasibility *The Collaborative should at a minimum include core prevention strategies. Supplemental prevention strategies also may be used. Most core and supplemental strategies are based on HICPAC guidelines. Strategies that are not included in HICPAC guidelines will be noted by an asterisk (*) after the strategy. HICPAC guidelines may be found at

Summary of Prevention Measures Contact Precautions for duration of illness Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and environment Laboratory-based alert system CDI surveillance Education Prolonged duration of Contact Precautions* Presumptive isolation Evaluate and optimize testing Soap and water for HH upon exiting CDI room Universal glove use on units with high CDI rates* Bleach for environmental disinfection Antimicrobial stewardship program Core MeasuresSupplemental Measures * Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

Upcoming DPH activities Commissioner’s Call to Action for antimicrobial stewardship Antimicrobial stewardship survey of acute care hospitals, later follow with LTCFs Posting of hospital-specific 2012 CLABSI, CAUTI, and SSI (COLO, HYST) data on DPH website Nursing Home HAI Prevalence and Antimicrobial Use Survey pilot 2014, full survey 2016