CDI prevention: A call to action for nursing homes Nimalie Stone, MD, MS Medical Epidemiologist for LTC Dialysis and LTC Team Division of Healthcare Quality Promotion CT CDI prevention collaborative April 9, 2014

Presentation objectives Describe how C. difficile infection (CDI) prevention fits within the national infection prevention priorities for nursing homes (NH) Explore the CDI surveillance and prevention resources available to NHs Share success stories from other state-led CDI prevention programs which engage NHs

Importance of infection prevention programs in NH NH residents are vulnerable to infections Frailty population with complex medical care needs increases risk of healthcare-associated infections (HAIs) Shared living environment allows for spread of infections Awareness of serious complications from infections for NH residents Driver of antibiotic use and antibiotic resistant bacteria Primary cause of transfers to hospital (30-day readmission) Heightened expectations for NH infection prevention Significant revisions to F441 interpretive guidance in Fall 2009 F441 citations are among the most frequently identified NH deficiencies

Challenges for NH infection prevention programs Limited time and support for infection prevention program coordinators Most have multiple roles/responsibilities in the facility, Rarely receive dedicated training on infection control Limited guidance for HAI prevention practices specifically for NH and other long-term care settings Current guidelines often focus on hospital practices Need for standards in use of infection surveillance definitions and data collection methods by NH programs Lack of national HAI prevention benchmarks for NHs

HHS National Action Plan to Prevent HAIs: LTC Chapter http://www.hhs.gov/ash/initiatives/hai/actionplan/index.html .

Priorities for infection prevention in LTC Priority areas for skilled nursing facilities and nursing homes: Promoting enrollment and reporting into the NHSN LTCF Component Reporting Clostridium difficile infections (CDI) in NHSN Reporting Urinary tract infections (UTI) in NHSN Increasing resident influenza and pneumococcal vaccination coverage reported in the CMS Minimum Data Set 3.0 Increasing Healthcare Personnel (HCP) influenza vaccination coverage during each annual influenza season The 5 priority areas for nursing homes are listed here. The first goal is to promote enrollment and reporting into the National Healthcare Safety Network Long-term care facility Component. Once facilities are using NHSN, the next two goals focus on reporting specific infection events, both C. difficile infections and urinary tract infections into the system. The 4th and 5th goal focus on increasing vaccination coverage among both residents and healthcare personnel in these facilities. LTC HAI Work Group Update. Presented at 2012 Progress Towards Eliminating Healthcare-Associated Infections Meeting, Washington DC. November 27, 2012

National infection reporting system CDC managed web-based system designed for healthcare facility reporting of infections Uses standardized infection definitions to identify events Data used by facilities for surveillance and internal quality improvement Data used by CDC to establish national benchmarks and track overall improvement in efforts to prevent healthcare-associated infections NHSN use for HAI reporting is part of many state and federal quality reporting programs for several healthcare settings Currently NHSN use by long-term care facilities is voluntary But, I’m excited to say, that CDC is committed to meeting those challenges for LTC. I’m not sure if everyone on the call is familiar with the National Healthcare Safety Network. This is web-based data collection system, developed and managed by CDC, for HAI reporting by healthcare facilities. It is over 30 years old, much of the work originating and tailored for use by acute care hospital providers. The system does provide a standard set of HAI surveillance definitions and mainly focuses on high-risk infection events, such as those related to device use or from multidrug-resistant bacteria. Recently, efforts have undergone to tailor reporting tools for distinct healthcare providers, rather than asking everyone to use the tools built for hospital reporting.

NHSN Long-term care facility component NHSN reporting option specifically for LTCFs 165 facilities have enrolled since its launch in Sept 2012 www.cdc.gov/nhsn/ltc

Modules & Events Healthcare-associated Infection Module Urinary tract infection (UTI) events Both catheter- and non catheter-associated Laboratory Identified (Lab-ID) Event Module C. difficile infections (CDI) Multidrug-resistance Organisms (MDRO) Including: Methicillin-resistant Staphylococcus aureus, Vancomycin-resistant Enterococcus, Resistant E. coli and Klebsiella Preventions Process Measures Module Hand hygiene adherence (observations) Gown and glove use adherence (observations)

Priority Area 1: National Healthcare Safety Network Enrollment Opportunity: Promote a standardized HAI surveillance methodology Utilize national reporting infrastructure for LTCFs Obtain national NH data on incidence of targeted HAIs Challenges: Lack of experience with NHSN for reporting infections Limited NH resources (e.g., staff, IT) Goal: 10% of certified nursing homes enrolled by 2017* *proposed new targets for NHSN enrollment – pending HHS review and approval NHSN enrollment was selected as a priority area because of the opportunity to promote the use of standard surveillance methodology and national HAI reporting system by skilled nursing facilities and nursing home providers. Over time, the data submitted into this system will provide national data on the incidence of targeted HAIs from this setting. However, we recognize that compared to acute care hospitals, nursing homes and skilled facilities have less staff and resources dedicated to their infection surveillance and prevention programs. These limitations in surveillance experience and support were taken into account when the working group set the initial 5-yr goal for enrolling 5% of eligible certified nursing homes into the NHSN system. The LTCF Component was released for users just 1 year ago today and I’m excited to share with you in the next few slides some data about the facilities which have started using the system.

NHSN SNF/NH users by state, 3-2014 <5 31-50 5-15 51-75 16-30 >75 26 states: 164 facilities; 1 NH from Connecticut

Facility size and resident services Median bed size: 120 (Range 10 – 815) Average percent occupancy: ~96% Percent of facilities providing the following services: <=50 beds 51-100 beds 101-199 beds >200 beds 18 (15%) 22 (18%) 53 (44%) 28 (23%) Long-term General Nursing Service Long-term Dementia Service Skilled Nursing Service Long-term Psychiatric Service Ventilator Service Bariatric Service Hospice/ Palliative Service 95% 68% 87% 31% 26% 33% 58%

Facility infection prevention resources Average staff hours spent each week on infection prevention and control activities Average total hours spent on infection prevention: 17.5 hours Average hours spent on surveillance: 9 hours (~50% of total) Infection prevention average staff hours by facility size Infection prevention average staff hours by affiliation <=50 beds 51-100 beds 101-199 beds >200 beds 8.6 hours 16.1 hours 18.1 hours 24.5 hours Hospital-based Independent Multi-facility organization 12.6 hours 18.4 hours 21.8 hours

Priority Area 2: C. difficile infection Opportunity: To track the national incidence of nursing home (NH) associated C. difficile infections (CDI) Challenges: Limited experience field testing validity of positive C. difficile lab tests as a proxy for infections in long-term care settings Insufficient data available to set benchmarks and targets Goal: Evaluate first 3-5 years of reported data to establish national baselines

C.difficile infection (CDI) in LTC CDI is the most common cause of acute diarrhea in LTC NH/SNF residents with multiple risk factors for colonization and infection Antibiotics are a major driver of C. difficile acquisition and infection Fluoroquinolone antibiotics associated with severe CDI Longer exposure = higher risk >64 McDonald LC et al Emerg Infect Dis 2006; Simor AS, J Am Geratrc Soc. 2010

Nursing homes account for a substantial burden of healthcare related CDI 75% of these outside hospitals Nursing home residents Patients in community Outpatient exposures only Recent inpatient exposure Post-discharge CDI common Most potent antibiotics used in hospitals Lasting effect on patients CDC, MMWR;2012;61: 1-6

Recent hospitalization linked to nursing home onset CDI Over 50% of nursing home onset incident CDI cases occurred within 4 weeks of a hospital discharge Pawar D. et al, ICHE 2012; 33: 1107-1112

Tracking CDI using positive lab tests NHSN laboratory identified (Lab-ID) CDI events Laboratory cultures used as a proxy for surveillance Definitions will match the Lab-ID event criteria being applied across healthcare settings This method is based solely on laboratory data and limited resident admissions/transfer data This ONLY includes results of testing performed on residents while at the facility Clinical evaluation of resident is not required, and therefore this surveillance option is less labor intensive Use of diagnostic testing for CDI could influence numbers of reportable events Some of the specifics about the LTC component are listed here. There is an annual survey designed specifically for LTC providers. The event reporting forms and surveillance methods are simplified and applicable for LTCF use. There is an infection surveillance event to capture urinary tract infections, both catheter and non-catheter associated. There are also a laboratory identified events where positive cultures act as a proxy for infections. This can be used to track C difficile infections as well as several different multidrug-resistant organisms. Finally there is a separate module to report prevention process measures such as hand hygiene adherence or use of gowns/gloves.

Identifying a NHSN CDI LabID Event

Advancing Excellence Infection goal www.nhqualitycampaign.org

Data for monitoring: AE CDI data collection tool Excel spreadsheet Helps facility to track CDI lab-events using the NHSN LTCF definitions Includes optional data fields to capture process measures Time from identifying diarrhea to testing stool Time from identifying diarrhea to starting precautions Provides graphs/charts as data is entered Some of the specifics about the LTC component are listed here. There is an annual survey designed specifically for LTC providers. The event reporting forms and surveillance methods are simplified and applicable for LTCF use. There is an infection surveillance event to capture urinary tract infections, both catheter and non-catheter associated. There are also a laboratory identified events where positive cultures act as a proxy for infections. This can be used to track C difficile infections as well as several different multidrug-resistant organisms. Finally there is a separate module to report prevention process measures such as hand hygiene adherence or use of gowns/gloves.

AE CDI data collection tool: Specimen log

Identifying opportunities for improvement Four prevention strategies identified for process improvement Early diagnosis/rapid containment of CDI Hand hygiene Environmental cleaning/disinfection Antibiotic stewardship Successful implementation of many of these strategies will reduce spread of other MDROs in the nursing home in addition to C.diff

Resources for the AE Infection goal Fact sheets about C. difficile infection prevention Consumers; nursing home staff; leadership Assessment checklists for each of the 4 prevention strategies with questions assessing Knowledge and competency Infection prevention policies and infrastructure Monitoring practices Links to websites with tools and resources to help address gaps identified by the assessment checklists Resources developed AE working group in partnership with CDC Representing nursing home expertise in infection prevention, clinical care, and quality improvement

Example assessment checklist Early identification and containment Yes/No format to assess current practices May identify opportunities for new practices http://www.nhqualitycampaign.org/star_index.aspx?controls=InfectionsImprove

Example assessment checklist cont.

AE CDI data collection tool: Measuring process improvement

AE CDI data collection tool: Reporting outcomes Provides your summary CDI data by month Based on monthly resident admission and average daily census provide on separate tab in worksheet Submit data to AE website to see your rates compared with others in the campaign

What about tracking CDI using NHSN? The AE data collection tool will help you gather all the important data needed to report events into NHSN Eventually, nursing homes may enroll and use NHSN for reporting, and use AE tools for prevention Using AE tools will teach facilities the NHSN surveillance process while also supporting their internal QI activities www.cdc.gov/nhsn/ltc/ltc-enroll-steps.html

State successes in NH CDI prevention Vermont, Sept 2010-ongoing, focus on MDRO/CDI Acute care and LTCFs partnered into local “healthcare clusters” Developed infrastructure to extract electronic data from acute and LTCF sharing laboratory services Enrolled 75% of VT skilled facilities into NHSN LTCF Component Massachusetts, July 2012- June 2013, CDI and urinary tract infections (UTI)  linked by antibiotic use 31 LTCFs (comparing pre/post-intervention periods) 28% decrease in urine culture testing; 33% reduction in reported UTIs; 45% reduction in C. difficile infection rate Kentucky, 2011-ongoing, focus on CDI/UTI Improved infection prevention knowledge in NHs -- better diagnosis and management of UTI State surveyors attending infection prevention trainings 14 NHs enrolled in NHSN LTCF component

For additional infection prevention resources: CDC LTC website www.cdc.gov/longtermcare

Benefits to getting involved now SNF/NHs need to invest in their infection prevention program activities National infrastructure to support HAI surveillance and prevention programs are available and growing State HAI programs are working closely with LTC providers Activities to reducing CDI will reduce spread of many infections and improve antibiotic use These activities will lead to better resident outcomes; fewer hospitalizations; and less antibiotic resistance Engaged nursing homes will be prepared for the future Data and performance improvement activities for QAPI Familiarity with NHSN enrollment and reporting activities Seen as Infection prevention and resident safety champions

Thank you!! Email: nstone@cdc.gov with questions/comments National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion