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National Center for Emerging and Zoonotic Infectious Diseases
Implementing Infection Prevention and Control Practices in Post-Acute Care
Nimalie D. Stone, MD, MSMD, MS
Team Lead for LTC, Prevention and Response
Division of Healthcare Quality Promotion
Post-Acute Care Emerging Multidrug-Resistant Organisms (MDRO) Education Symposium
January 21, 2020
▪ No conflicts to disclose
▪ The content of this presentation reflects my opinion and does not necessarily reflect the official position of the CDC
Speaker Disclosures
▪ Describe the importance of post-acute care settings during regional containment of resistant pathogens
▪ Discuss infection prevention and control practices for preventing spread of Carbapenem-Resistant Acinetobacter baumannii (CRAB) and other multidrug-resistant organisms (MDROs)
Presentation Objectives
Healthcare delivery shifting away from hospitals…
Tranquil GardensNursing Home
HomeCare
Acute Care
Facility
Outpatient/Ambulatory
Facility
Post-acute/Long-term care
Post-acute care (PAC) settings
▪ Long-term “acute” care hospital (LTACH)
▪ Inpatient rehabilitation facility (IRF)
▪ Skilled nursing facility (SNF)/Nursing Home (NH)
▪ Home health
MDRO risk factors among individuals receiving post-acute care
▪ Indwelling medical devices (e.g., urinary catheter, PEG tube, trach, central line)
▪ Presence of wounds or decubitus ulcers
▪ Antibiotic use in prior 3 months, particularly fluoroquinolones
▪ Recent hospitalization
▪ Comorbid medical conditions
▪ Increased functional dependence
McKinnell JA et al. Clin Infect Dis. 2019; Feb 11. doi: 10.1093/cid/ciz119. [Epub ahead of print]
Burden of MDROs in Post-acute care
58% median MDROcarriage
82% median MDROcarriage
76% median MDROcarriage
NHs (n=14)
NH with ventilator units (n=4)
LTACH (n=3)
▪ Frequent pathogens: MRSA (25-40%) and ESBL (~20%)
▪ Median CRE prevalence: 10% in NHs with vents;
McKinnell JA et al. Clin Infect Dis. 2019; Feb 11. doi: 10.1093/cid/ciz119. [Epub ahead of print]
Burden of MDROs in Post-acute care
58% median MDRO
carriage
82% median MDRO
carriage
76% median MDRO
carriage
NHs (n=14)
NH with ventilator units (n=4)
LTACH (n=3)
DOCUMENTED MDRO: 17%
DOCUMENTED MDRO: 20%
DOCUMENTED MDRO: 50%
Healthcare transfer networks drive regional MDRO spread
▪ Transfer of individuals colonized or infected with MDROs contributes to transmission across healthcare facilities
▪ Initial entry of CRAB and other MDROs into post-acute facilities can be unrecognized
▪ Factors leading to amplification of MDROs in post-acute care facilities ▪ Longer length of stay
▪ Increased complexity of care
▪ Decreased staff: patient ratios
▪ Gaps in IPC programs and practices
Won SY et al. Clin Infect Dis. 2011;53(6):532-540.
Containment and Prevention of MDROs
IPC program implementation challenges: Lessons learned
▪ Limited administrative support, staff time and resources for infection prevention and control activities
▪ Gaps in adherence to hand hygiene, limited access to alcohol-based hand rubs
▪ Limited access to personal protective equipment (PPE) and minimal use of Contact Precautions
▪ Improper product selection, use and access to reduce environmental surface contamination within shared rooms
▪ Inadequate cleaning/disinfection of equipment shared between residents
▪ Inadequate communication of MDRO history or risk factors during facility transfers
▪ Challenges with staff turnover and need for continuous training to sustain efforts
Infection prevention and control (IPC) practices
MDRO Prevention: Novel and Core Strategies
MDRO Prevention Strategies: Back to Basics
Hand HygienePersonal Protective
Equipment & PrecautionsEnvironmental
Cleaning & Disinfection
Hand Hygiene
Alcohol-based hand rub (ABHR) is preferred over soap and water except when hands are visibly soiled.
- Effective against CRAB and other MDROs
- Immediate killing effect
- Less dependent on technique
- Placement of dispensers increases availability to HH supplies and improves adherence
https://www.cdc.gov/handhygiene/science/index.html
Support for ABHR Use
If hands are not visibly soiled, use an alcohol-based hand rub (ABHR)
“consistent with accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except when hands are visibly soiled (e.g., blood, body fluids), or after caring for a resident with known or suspected C. difficile or norovirus infection during an outbreak, or if infection rates of C. difficile are high…”
Literature:ABHR is a faster, more convenient, less drying method of HH for HCWs in a LTCF AND it improved compliance. ABHR was more efficacious than soap and water in removing pathogens already present on HCW hands.
Mody L. et al. ICHE 2003; 24(3):165-171
Hand Hygiene Education
▪ Proper hand hygiene techniques
▪ Indications for performing hand hygiene
– BEFORE patient/resident contact.
– BEFORE performing clean or aseptic tasks; BETWEEN moving from a dirty to clean site
– AFTER contact with blood, body fluids, mucous membranes or non-intact skin/wounds
– AFTER patient/resident contact
– AFTER touching the care environment
▪ Hand hygiene when using Personal Protective Equipment (PPE)
– Before donning PPE and after removal
– Gloves are NOT a substitute for performing hand hygiene.
Ensure Access to Hand Hygiene Supplies
▪ Evaluate current availability of sinks and ABHR in high acuity units
▪ Place ABHR dispensers in patient/resident care locations▪ Inside and outside of resident rooms
▪ Common areas
▪ Staff work stations
▪ Therapy rooms
▪ Develop a process and identify personnel to monitor and restock HH supplies
Training, Auditing and Feedback
▪ Create a culture of safety to encourage peer to peer hand hygiene reminders
▪ Utilize competency-based training activities▪ Caught “red-handed”
▪ Fluorescent gel hand washing exercise
▪ Develop an auditing and feedback program
▪ Train “secret shoppers” to observe hand hygiene practices
▪ Record and summarize data routinely (e.g. monthly or quarterly
▪ Provide feedback to front-line staff
http://professionals.site.apic.org/files/2013/10/ICW_Planner_2012.pdf
Personal Protective Equipment (PPE) & Precautions
Standard Precautions
Transmission-Based
Precautions
Standard Precautions
PPE
Hand Hygiene
Injection &
Medication Safety
Respiratory Hygiene &
Cough Etiquette
Environmental Cleaning &
Disinfection
Reprocessing of Reusable
Medical Equipment
Contact Precautions for MDROs
▪ Perform hand hygiene
▪ Gown and gloves upon room entry
▪ Dedicated equipment
▪ Private room
▪ Room restriction
Difficulty in Applying Transmission-Based Precautions for MDROs in Nursing Homes
▪ “Transmission-Based Precautions must be used when a resident develops signs and symptoms of a transmissible infection”
▪ “Facility policies must identify type and duration of Transmission-Based Precautions”
▪ “Transmission-Based Precautions should be the least restrictive possible for the resident based on his/her clinical situation and used for the least amount of time”
▪ “Once the resident is no longer a risk for transmitting the infection… removing Transmission-Based Precautions is required”
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Rev. 173, 11-22-17.State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities [PDF – 749 pages]
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Difficulty in Applying Transmission-Based Precautions for MDROs in Nursing Homes
▪ “Transmission-Based Precautions must be used when a resident develops signs and symptoms of a transmissible infection”
▪ “Facility policies must identify type and duration of Transmission-Based Precautions”
▪ “Transmission-Based Precautions should be the least restrictive possible for the resident based on his/her clinical situation and used for the least amount of time”
▪ “Once the resident is no longer a risk for transmitting the infection… removing Transmission-Based Precautions is required”
Colonization ≠ Infection
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Rev. 173, 11-22-17.State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities [PDF – 749 pages]
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Difficulty in Applying Transmission-Based Precautions for MDROs in Nursing Homes
▪ “Transmission-Based Precautions must be used when a resident develops signs and symptoms of a transmissible infection”
▪ “Facility policies must identify type and duration of Transmission-Based Precautions”
▪ “Transmission-Based Precautions should be the least restrictive possible for the resident based on his/her clinical situation and used for the least amount of time”
▪ “Once the resident is no longer a risk for transmitting the infection… removing Transmission-Based Precautions is required”
Colonization ≠ Infection
Duration of MDRO colonization can be prolonged (>6 months)
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Rev. 173, 11-22-17.State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities [PDF – 749 pages]
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Difficulty in Applying Transmission-Based Precautions forMDROs in Nursing Homes
▪ “Transmission-Based Precautions must be used when a resident develops signs and symptoms of a transmissible infection”
▪ “Facility policies must identify type and duration of Transmission-Based Precautions”
▪ “Transmission-Based Precautions should be the least restrictive possible for the resident based on his/her clinical situation and used for the least amount of time”
▪ “Once the resident is no longer a risk for transmitting the infection… removing Transmission-Based Precautions is required”
Colonization ≠ Infection
Duration of MDRO colonization can be prolonged (>6 months)
Resident remains at risk for transmitting the MDRO even when not actively infected
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Rev. 173, 11-22-17.State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities [PDF – 749 pages]
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization,
which can persist for long periods of time (e.g., months), and result in the silent spread of MDROs.
The Need for a New Approach
▪ Clarification of how and when to use PPE and room restriction to prevent the spread of MDROs
▪ Balanced approach to managing the prolonged colonization and preventing the silent spread of MDROs
▪ Addresses care of nursing homes residents at-risk of acquiring colonization
Enhanced Barrier Precautions (EBP): Guidance for Nursing Homes to Prevent MDRO Spread
Implementation of PPE in Nursing Homes to Prevent Spread of Novel or Targeted MDROs https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
“Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated
and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.”
High-contact Resident Care Activities
▪ Dressing
▪ Bathing/showering
▪ Transferring
▪ Providing hygiene
▪ Changing linens
▪ Changing briefs or assisting with toileting
▪ Device care or use of a device: central line, urinary catheter, feeding tube, tracheostomy/ventilator
▪ Wound care: any skin opening requiring a dressing
Resistant Gram-negative Bacteria (RGNB) Transmission to Gowns and Gloves of HCW during Care of Colonized Residents▪ Highest Risk:
Showering
Hygiene
Toileting
Wound dressing changes
▪ Lowest Risk:
Assist feeding
Giving meds
Glucose monitoring
Blanco et al. Infect Control Hosp Epidemiol (2018), 39, 1425-1430
Enhanced Barrier Precautions should be usedfor all Nursing Home residents with any of the following:
▪ Infection or colonization with a novel or targeted MDRO (as of July 2019) defined as:
Pan-resistant organisms,
Carbapenemase-producing Enterobacteriaceae,
Carbapenemase-producing Pseudomonas spp.,
Carbapenemase-producing Acinetobacter baumanii,
Candida auris
▪ Wounds and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status residing in the same unit/ward
▪ When Contact Precautions do not apply
Contact Precautions should be used:
▪ All residents infected or colonized with a novel or targeted multidrug-resistant organism in specific situations:
Presence of acute diarrhea, draining wounds or other sites of secretions or excretions that are unable to be kept covered or contained
On units or in facilities where ongoing transmission is documented or suspected
▪ For infections (e.g., C. difficile, norovirus, scabies) and other conditions where Contact Precautions is recommended
See Appendix A – Type and duration of Precautions Recommended for Selected Infections and Conditions of the CDC Guideline for Isolation Precautions
Personal Protective Equipment (PPE) & Precautions
Standard Precautions
Enhanced Barrier
Precautions
Contact Precautions
Required PPE forEnhanced Barrier Precautions vs. Contact Precautions
Enhanced Barrier PrecautionsApplies to:
Gloves and gown prior to the high-contact care activity
Note:
• Does not require single-person room
• Does not require restrictions of movement/participation within facility policy.
Contact PrecautionsApplies to:
Gloves and gown
Note:
• Includes consideration for single-person room or cohorting
• Includes restriction of movement and participation in group activities within the facility
Enhanced Barrier Precautions: Quick Summary
▪ WHO: Residents colonized with Novel or Targeted MDROs
AND residents with wounds and/orindwelling medical devices
ON THE SAME UNIT
▪ WHAT: Gown and glove use for high-contact resident care activities
▪ WHERE: Nursing Homes
▪ WHEN: Novel or Targeted MDRO isidentified in the facility
▪ WHY: Prevent the spread of MDROs andPROMOTE RESIDENT SAFETY
Implementing Precautions: Clear Signage
▪ Identifies the type of Precautions
– Generic “STOP/See nurse” signs are not adequate
▪ Includes the required PPE:
– Lists the high-contact resident care activities for gown/glove use
▪ Displayed immediately outside of resident room
▪ PPE available at resident room with process for restocking supplies
▪ Access to alcohol-based hand rub prior to donning PPE and after PPE removal
▪ Use dedicated equipment whenever possible
▪ Access to cleaning supplies such as disinfecting wipes for shared equipment
Implementing Precautions: Access to Supplies
Auditing Practices and Education
▪ Incorporate periodic monitoring and assessment of adherence to determine need for additional training and education
Environmental Cleaning: General Principles
▪ Establish a standard process that ensures consistency and prevents cross-contamination
– Working around the room in same direction every time
– Starting from highest surfaces and work down
– Always moving from clean areas to dirty
Environmental Cleaning: Focus on high touch surfaces
Implement more frequent cleaning/ disinfection for surfaces likely to be contaminated:
▪ Bed and chair rails
▪ Bedside tables
▪ Call light
▪ Remote control and phone
▪ Sink and toilet
▪ Light switches, knobs and door handles
Environmental Cleaning: Understanding Contact Times and Product Instructions
▪ Contact Time: amount of time a surface should be exposed to a disinfectant to kill pathogens
▪ Must follow product guidance and instructions for use
▪ Selecting products with long contact times (>10min) may not be practical
▪ Clear labeling helps staff use products appropriately for maximum effect
Monitoring Quality of Environmental Cleaning
▪ Develop an auditing & feedback program
– Direct observation to evaluate use of appropriate products and procedures
– Evaluate consistency of cleaning by use of fluorescent gel markings
– Record and summarize data routinely (e.g. monthly or quarterly
– Provide feedback to EVS/Housekeeping staff
Cleaning and Disinfection of Shared Medical Equipment
▪ Shared medical equipment must be cleaned and disinfected prior to use with another resident
▪ Easy access to appropriate cleaning/ disinfectant products at point of use
▪ Coordination between nursing, rehabilitation, and housekeeping/EVS staff to determine “Who cleans what?” and frequency of cleaning equipment
“Who Cleans What??” checklist
Examples of success: Supporting the IPC program activities
▪ Individual responsible for IPC program receives dedicated time and training to oversee program and practice implementation
▪ Facility administrative and clinical leaders allocate resources and provide support for IPC program activities
▪ Team approach to implementation of IPC practices with infection prevention, front-line nursing staff, EVS/Housekeeping staff, and other ancillary staff
▪ Staff receive competency-based education and have access to supplies to support adherence to IPC practices
▪ Ongoing monitoring and feedback of adherence to IPC practices used to identify and address barriers, maintain staff awareness, and ensure consistency of practices
Communication at time of Transfer
Actions to Improve Infection Prevention and Control
In light of recent reports of healthcare-associated infections in nursing homes, such as adenovirus and Candida auris, facilities are reminded of their responsibility for an effective infection prevention and control program to mitigate the onset and spread of infections. Basic practices include: • Appropriate hand hygiene. As a reminder, alcohol-based handrub (ABHR)
should be used instead of soap and water in all clinical situations except when hands are visibly soiled (e.g., blood, body fluids), or after caring for a resident with known or suspected C. difficile or norovirus infection during an outbreak; in these circumstances, soap and water should be used. Facilities should ensure adequate access to ABHR since a main reason for inadequate hand hygiene adherence results from poor access;
• Appropriate use of personal protective equipment (PPE). Facilities need to ensure sufficient access and use of PPE, such as gowns and gloves in resident care areas/near the entrance to resident rooms, and appropriate education about the importance of PPE;
Actions to Improve Infection Prevention and Control (continued)
• Environmental cleaning and disinfection. Clean and disinfect the resident's care environment and shared equipment with agents effective against the identified organism or products on an EPA-registered antimicrobial list recommended by public health authorities. It is important to follow all manufacturer’s directions for use for a surface disinfectant including applying the product for the correct contact time. Facilities need to ensure adequate access to supplies and proper instruction for staff (nursing or housekeeping/environmental services) responsible for cleaning pieces of equipment;
• Implementation of transmission-based precautions when indicated; • Providing adequate surveillance and identification of resident diagnoses of
infections or multidrug-resistant organism (MDRO) colonization status admitted to your facility to understand the types of infections and causative agents present; and
• Identifying and communicating at the time of transfer into and out of a facility the infection and/or MDRO colonization status of residents so appropriate measures can be implemented.
Actions to Improve Infection Prevention and Control (continued)
Additionally, we strongly encourage the use of available technical resources, especially when novel organisms appear or there is an outbreak in your area. In many cases the Centers for Disease Control and Prevention is the first entity to release information on novel organisms. Your local and state health department may also be a resource on information specific to the prevalence of a specific organism in your area and actions to take. All facilities must comply with state and local public health authority requirements for identification, reporting, and containing communicable diseases and outbreaks. Many infection prevention and control resources are available to you to prevent and control infections in your facility.
Resources
Online resources
https://www.cdc.gov/drugresistance/biggest-threats.html#acine
https://www.cdc.gov/hai/organisms/acinetobacter.html
CDC Nursing Home IP Training Course
❑ Curriculum designed to cover the core activities and practices of a NH IPC program
❑ Web-based, self-study modules; close to 20 CE hours
❑ Based on CDC guidance and best-practice recommendations
❑ Target audience – nursing home staff given responsibility for IPC program implementation
https://www.train.org/cdctrain/training_plan/3814
https://www.cdc.gov/hai/containment/guidelines.html
CDC Containment Guidelines and Resources
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Thank you!
Questions/commentsEmail: nstone@cdc.gov
Email:
https://www.cdc.gov/longtermcare/index.html
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