1. Session 61, Track A: Reducing Healthcare- Associated Infections (HAIs) in Long-Term Care (LTC): Current Strategies and Challenges AHRQ Annual Meeting August 7, 2012 Nursing Home Staffing Lance R. Peterson, MD Epidemiologist Director, Microbiology and ID Research NorthShore University HealthSystem, Evanston, IL NorthShore University HealthSystem, Evanston, IL Clinical Professor, University of Chicago Chicago, IL USA

2. The ‘DERAIL MRSA’ Program ( The ‘DERAIL MRSA’ Program (Detection, Education, Research And decolonization without Isolation in Long-term care to control MRSA) Goal: Develop a strategy for Infection Control and Prevention in Acute care to Partner with LTCFsGoal: Develop a strategy for Infection Control and Prevention in Acute care to Partner with LTCFs –Program began in early 2011; MRSA was proof of concept pathogen –To date more than 8,500 MRSA tests done on LTCF patients as part of periodic resident testing and all admission surveillance –Close relationship between 3 nursing home senior management and IPs

3. Overall Incidence of Organisms in LTCFs Viray M, et al. Infect Control Hosp Epidemiol. 2005;26:56-62. (n=4,954) Percent of isolates 3

4. Leverage of Acute Care Data What is the Extent of the NI Problem? (22,944 Admissions) LTC Facility NameTotal PatientsMRSA carriers% carriersMean Age LTC A563053.684.5 LTC B311445.285.2 LTC C281035.788.7 LTC D25728.083.9 LTC E26726.960.8 LTC F35822.982.9 LTC G23521.787.3 LTC H751418.787.0 LTC I24416.785.7 LTC J761114.585.1 LTC K49714.389.1 LTC L50714.083.2 LTC M31412.987.0 LTC N32412.587.3 LTC O33412.183.2 LTC P68811.885.4 LTC Q2015.052.8 * * 10 infections over the last 25 months *

5. Can Acute Care Leverage IC Practice in LTCFs? Initial discussion with LTCF manager elicited little interest in working with acute hospital IC groupInitial discussion with LTCF manager elicited little interest in working with acute hospital IC group –IC ‘assigned’ to senior nursing staff Acute care organization leadership indicated need to cease use of ‘high risk’ LTCFsAcute care organization leadership indicated need to cease use of ‘high risk’ LTCFs Owner requested Epidemiologists to visit and discuss how to improve IC in LTCFsOwner requested Epidemiologists to visit and discuss how to improve IC in LTCFs –Agreed to hire full time IP

6. What About LTCF Staff Turnover? All staffAll staff –Comprehensive review found inconsistent and contradictory conclusions regarding staffing and care quality - K Spilsbury et al. Intl J Nurs Studies 48:732-50, 2011 –Recent state-wide report (2002-2009) found retention (experience) lowered hospital readmission but turnover (frequent change in selected positions) did not - KS Thomas et al. The Gerontologist (Adv. Access Aug 30, 2012 IP staffIP staff –No reports found –The number of beds justifying a full time IP is not known - 2008 SHEA/APIC LTCF Guideline

7. Acute Care and LTCF Relationship Annual visit to meet with LTCF managers and senior staff/ownersAnnual visit to meet with LTCF managers and senior staff/owners IPs from LTCFs invited to attend weekly IC meeting at Acute Care facilityIPs from LTCFs invited to attend weekly IC meeting at Acute Care facility IPs from LTCFs encouraged to call Acute Care IP whenever consultation is neededIPs from LTCFs encouraged to call Acute Care IP whenever consultation is needed

8. Questions for Consideration What strategies have you used to engage LTCF leadership interest in an ongoing relationship with IC that is more readily available in acute care facilities? Have you observed any organizational models that enhance general staff commitment to LTCFs – are there incentives that work and disincentives to avoid? Do you have any idea(s) on how to specifically stabilize IP (IC) staff to reduce turnover/increase retention for these workers in LTCFs?