1. 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

2. 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

3. 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

4. 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

5. HHS National Action Plan to Prevent HAIs: LTC Chapter.

6. 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

7. 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.

8. NHSN Long-term care facility component
NHSN reporting option specifically for LTCFs
165 facilities have enrolled since its launch in Sept 2012

9. 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)

10. 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.

11. NHSN SNF/NH users by state, 3-2014
<
>75
26 states: 164 facilities; 1 NH from Connecticut

12. 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
beds
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%

13. 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
beds
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

14. 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

15. 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

16. 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

17. 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:

18. 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.

19. Identifying a NHSN CDI LabID Event

20. Advancing Excellence Infection goal

21. 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.

22. AE CDI data collection tool: Specimen log

23. 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

24. 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

25. Example assessment checklist
Early identification and containment
Yes/No format to assess current practices
May identify opportunities for new practices

26. Example assessment checklist cont.

27. AE CDI data collection tool: Measuring process improvement

28. 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

29. 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

30. 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 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, 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

31. For additional infection prevention resources: CDC LTC website

32. 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

33. Thank you!!
with questions/comments
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion