1. James Marx, PhD, RN, CIC, FAPIC Broad Street Solutions October 2016

2.  None

3.  Revise the description of the infection control program by adding new requirements and update the program  Integrate the infection prevention and control program (IPCP) with the facility’s QAPI processes  Create a facility-specific assessment of their resident population and facility

7.  July 2015: CMS proposed new Federal Regulations for LTCFs ◦ Designated infection prevention and control (IPC) officer ◦ Annual facility risk assessment and review/update IPC program and policies ◦ IPC specific education and training for all staff  September 2015: CDC released the Core Elements of Antibiotic Stewardship for Nursing Homes ◦ http://www.cdc.gov/longtermcare/pdfs/core-elements- antibiotic-stewardship.pdf http://www.cdc.gov/longtermcare/pdfs/core-elements- antibiotic-stewardship.pdf ◦ New stewardship questions added for 2016 LTCF annual survey  October 2015: CMS announced the C. difficile Infection Reporting and Reduction project within the nursing home 11th Scope of work for Quality Innovation Networks – Quality Improvement Organizations (QIN-QIO)

8.  CMS 11th Scope of Work C. difficile Reporting and Reduction Project ◦ Official contract start date- Monday, May 23, 2016 ◦ Recruitment and enrollment through October 2016 ◦ Project goal is to recruit 15% of nursing homes in the U.S. (~2300 NHs) to enroll into NHSN and sustain C. difficile infection (CDI) reporting using NHSN CDI LabID Event module ◦ Collaborative participants will receive training in long- term care communication (TeamSTEPPS) and antibiotic stewardship ◦ CDC will monitor changes in CDI rates among NHSN reporters before and after educational interventions ◦ Opportunity to establish a national baseline for CDI in nursing homes

9.  Expanded Training Resources for LTCFs ◦ Series of 6 Webinar trainings available on the following url: http://qioprogram.org/national-healthcare-safety-network- nhsn-trainings http://qioprogram.org/national-healthcare-safety-network- nhsn-trainings  Secure Access Management Services (SAMS)  NHSN enrollment  Setting up a facility in the NHSN  Reporting C. difficile LabID events  Analyzing C. difficile LabID events  Creating and managing group access for data sharing.  Additional enrollment training resources and guidance documents available on NHSN training and enrollment websites:  http://www.cdc.gov/nhsn/training/enrollment- setup/index.html http://www.cdc.gov/nhsn/training/enrollment- setup/index.html  http://www.cdc.gov/nhsn/training/ltc/index.html http://www.cdc.gov/nhsn/training/ltc/index.html

10.  Transitions in Care  Antibiotic Use  Food Safety  Infection Prevention and Control Program  Infection Preventionist  Quality Improvement and Staffing  Antimicrobial Stewardship  Staff Training

11.  Information should be provided during transitions of care: ◦ MDRO status ◦ Current or recent antibiotic use, indication and stop date ◦ Presence of indwelling devices ◦ Current transmission-based precautions status

12.  Use consultant pharmacist ◦ Review the medical records for appropriate use of antimicrobial medication in an evidence-based activity ◦ Monitor cumulative antibiotic use ◦ Monitor use of specific antibiotics ◦ Monitor antibiotic cost and trends ◦ Integrate with Quality Assurance and Performance Improvement (QAPI) process

13.  Adopt the FDA model Food Code for food preparation and service  Use HACCP program to provide the best protection against foodborne illness among the vulnerable populations served in these facilities

14.  Create an annual facility assessment  Incorporate relevant infection control data into the annual facility assessment ◦ Plans ◦ Goals ◦ Interventions  Implementation of a comprehensive IPCP  Adopt standardized HAI surveillance definitions developed by the CDC

15.  Change the term Infection Prevention and Control Officer (IPCO) to Infection Preventionist (IP)  Require formal training for the IP ◦ Consistent with the APIC and CBIC core competencies ◦ Endorsed or developed by professional infection prevention and control organizations  APIC; Society for Healthcare Epidemiology of America (SHEA)  Public health departments  Academic communities with public health or infection prevention expertise  Board-certified infection preventionists or healthcare epidemiologists with an understanding of the unique needs of the long-term care continuum

16.  IP as an active member of the quality assurance interdisciplinary team  Utilize the annual facility assessment and other models to help determine appropriate FTE for infection prevention staffing ◦ Proposal was for 6 hours/week/facility

17.  Move oversight responsibilities §483.30 Physician Services or §483.45 Pharmacy Services.  Oversight of the antibiotic stewardship program should be the responsibility of either a clinical pharmacist or medical director who works with the IPCP to implement the program

18.  Antibiotic use protocols  Systems for monitoring antibiotic utilization, and follow antibiotic susceptibility patterns (antibiograms) for the facility ◦ Must address nurse-LIP communication, nursing documentation, and provide staff and LIP education on when diagnostic testing is appropriate and needed.  Train IPs and staff nurses on the risks and benefits of antibiotic use

19.  Policies and procedures as they relate to infection prevention and control ◦ Tailored to audience ◦ Repeated regularly ◦ Based on national guidelines and recommendations from CDC and professional organizations such as APIC, SHEA, or IDSA.

20.  Personnel  Surveillance  Policy Development  Training/Education  MDRO Management  Care Delivery  Employee Health  Antimicrobial Stewardship

21.  Professional training  Networking  Certification in Infection Control (CIC)  Other activities ◦ Primary ◦ Secondary  Job Description  Performance Expectations

22.  Standard definitions  Case finding methods  Tracking mechanisms  Analysis  Identifying opportunities  Creating reports  Reporting findings  Disseminating results

23. Document  Hand Hygiene  Isolation Precautions  Cleaning and Disinfection  Environmental Cleaning  Safe Injection Practices  Bloodborne Pathogens  Airborne Transmissible Diseases              

24.  Staff training methods  IC training for non-clinical staff  Resident and Family education  Training materials in primary language other than English  Budget

25. Method  Identification  Surveillance Testing  Initiation of precautions  Discontinuation of precautions  Intrafacility communication  Roommate selection  HOT TOPIC: C. difficile              

26.  Hand Hygiene  Personal protective equipment  Environmental Cleaning  Antibiotic Utilization

27.  Vaccine preventable diseases  Immunization ◦ Hepatitis B ◦ Varicella ◦ MMR ◦ HOT TOPIC: Influenza  Tuberculosis screening

28.  Reduction in antimicrobial purchasing costs  Reduction in antimicrobial resistance  Reduction in C.difficile rates  Get SMART campaign Addo, 2011

29.  Determine risk matrix ◦ Likelihood ◦ Consequence  Identify systems and subsystems  List tasks and identify failures ◦ Causes and possible outcomes ◦ Existing control guidelines  Recommend additional controls

31.  Likelihood ◦ Likely 66-100% ◦ Possible 33-66% ◦ Unlikely 0-33%  Consequences ◦ Minor- can be managed without medical treatment ◦ Moderate- requires medical treatment ◦ Major- transfer to hospital or death

32.  Likelihood ◦ Likely 66-100% ◦ Possible 33-66% ◦ Unlikely 0-33%  Consequences ◦ Minor- can be managed without medical treatment ◦ Moderate- requires medical treatment ◦ Major- transfer to hospital or death

34.  System ◦ Physical layout  Subsystem ◦ Resident Room  Potential failures ◦ Insufficient number of private rooms  Causes ◦ Facility not designed with private rooms

35.  Consequences ◦ Transmission of microorganisms between residents  Controls ◦ 2006 CDC MDRO guideline  Recommendations ◦ Resident assessment to control body fluids ◦ Cohorting with like condition ◦ Consider contact precautions ◦ Environmental disinfection

36.  Likelihood ◦ Likely 66-100% ◦ Possible 33-66% ◦ Unlikely 0-33%  Consequences ◦ Minor- can be managed without medical treatment ◦ Moderate- requires medical treatment ◦ Major- transfer to hospital or death

37.  Likelihood ◦ Likely 66-100% ◦ Possible 33-66% ◦ Unlikely 0-33%  Consequences ◦ Minor- can be managed without medical treatment ◦ Moderate- requires medical treatment ◦ Major- transfer to hospital or death

39.  System ◦ Physical layout  Subsystem ◦ Resident Room  Potential failures ◦ Insufficient number of private rooms  Causes ◦ Facility not designed with private rooms

40.  Consequences ◦ Transmission of organisms between residents  Controls ◦ 2013 APIC Guide to preventing C. difficile infection  Recommendations ◦ Initiate contact precautions for residents with diarrhea ◦ Cohorting if necessary ◦ Decrease staff handling stool contaminated items ◦ Environmental disinfection ◦ Assess compliance with prevention measures

41.  Program Assessment Tool ◦ Determine baseline ◦ Identify opportunities for improvement ◦ Seek resources to achieve goals  Risk Assessment ◦ Identify risks ◦ Prioritize activities based on risk ◦ Implement control measures ◦ Assess progress

42.  WHO guidelines http://www.who.int/gpsc/5may/en/ http://www.who.int/gpsc/5may/en/ ◦ 2009 Hand Hygiene  CDC guidelines http://www.cdc.gov/HAI/settings/ltc_settings.html http://www.cdc.gov/HAI/settings/ltc_settings.html ◦ 2009 CAUTI ◦ 2008 Disinfection and Sterilization ◦ 2007 Isolation ◦ 2006 MDRO ◦ 2003 Environment ◦ 2002 Hand Hygiene ◦ 1998 Healthcare Personnel

43.  http://www.apic.org/Resource_/TinyMceFile Manager/Advocacy- PDFs/LTC_COP_Comments_--_Final_9-10- 15.pdf

44.  APIC guidelines http://apic.org/Professional-Practice/Implementation- guides http://apic.org/Professional-Practice/Implementation- guides ◦ 2015 Hand Hygiene ◦ 2013 Clostridium difficile ◦ 2011 Influenza vaccination ◦ 2008 CAUTI ◦ 2007 Surveillance ◦ 2009 MRSA in LTC  SHEA guidelines http://www.shea-online.org/GuidelinesResources/ Guidelines.aspx http://www.shea-online.org/GuidelinesResources/ Guidelines.aspx ◦ 2012 Definitions of Infection ◦ 2008 LTC Program

45.  New York State ◦ http://www.health.ny.gov/facilities/long_term_care http://www.health.ny.gov/facilities/long_term_care  ACHA ◦ https://www.ahcancal.org/qualityreport/Document s/AHCA_2014%20Quality%20Report%20FINAL.pdf https://www.ahcancal.org/qualityreport/Document s/AHCA_2014%20Quality%20Report%20FINAL.pdf

46. James Marx, PhD, RN, CIC, FAPIC Infection Preventionist Broad Street Solutions PO Box 16557 San Diego, CA 92176 619/656-7887 Voice Fax BroadStreetSolutions@icloud.com BroadStreetSolutions@icloud.com