multidrug-resistant organism prevention in the long-term care facility setting drugs, bugs and...

Multidrug-resistant organism prevention in the long-term care facility settingDrugs, Bugs and Scrubs

Vermont Department of Health Matthew Thomas

I. Presentation objective

II. Background I. Vermont MDRO CollaborativeII. CDC Baseline Survey

III. AssessmentI. Survey resultsII. Collaborative resultsIII. Survey limitationsIV. Collaborative limitations

IV.Overall limitations

V. Conclusions and recommendations

Presentation Outline

Assess utility of CDC baseline survey in context of Vermont MDRO Collaborative

Objective:

The Vermont MDRO Collaborative

Cluster Model

Acute care hospitals

Long term care facilities

Inter-facility transfer form

Contact Precautions

Hand Hygiene

Surveillance

Antimicrobial Stewardship

Decolonization

Environmental Cleaning

Urinary Catheterization

Electronic Data Transmission

Collaborative Trainings and Assessments

Learning Session Quarterly All day meeting, driven by clinical and data content

Action Period Quarterly Implementing interventions

Cluster Meetings Variable Planning for interventions

Cluster Coaching Survey

Bi-monthly Assessment of cluster activity

Point Prevalence Survey

Once Assessment of MDRO burden

MDRO Intervention Survey

Once Assessment of intervention implementation

Unstructured Contact Variable Variable, mainly concentrated on electronic data transmission

Webinar Variable Driven by clinical content

SepOct

NovDec

JanFeb

MarApr

MayJun

JulAug

Cluster Coaching Survey

Point Prevalence Survey

MDRO Intervention Survey

Unstructured Contact

Cluster Meetings

MDRO Collaborative Timeline

Sep

Action PeriodAction Period Action Period

Learning Session 2

Learning Session 1

Learning Session 3

Learning Session 4

Baseline Assessment

Webinars

1.Evaluate the status of infection prevention and control

2.Understand what is being done to develop implementation strategies and determine next steps

3.Measure changes in practice

4.Determine the extent to which targets are being met

5.Determine the effectiveness of outcomes being achieved

Goals of Baseline Assessment Tool

Primary Role of Respondent

• Staff Educator (36%); Director of Nursing (29%); Infection Preventionist (19%)**

• Average of 3.8 years in that position

Type of Facility

• Long term facility care (94%); Skilled nursing/short term rehab (90%)

• Average of 105 beds and 91% annual occupancy

• For-profit institutions (65%)**

• Independent, free standing (42%); Multi-facility chain (39%)**

Basic Facility Demographics

**From mutually exclusive categories

Infection Control (IC) Program Personnel

No. of years of IC experience, (mean) 9.8

No specific infection control training (%)** 74

Part time coordination of infection control (%)** 90

**Categories are mutually exclusive

One Less than one

NoneMore than one

50%

23%

16%10%

Nu

mb

er

of

FT

Es

Survey Says…. Collaborative Says….

Survey Missed… Collaborative Missed…

•60% have one or more FTE•10 years of IC experience•No specific IC training•90% IC is a part time role

• Need a clearer distinction

between FTE and part time• Need an assessment of tech

experience, training, access

•Cluster coaching:

• 79/108 (73%) to IP

• Includes both AC and

LTC

• What tasks are reasonable

in a low resource setting?•Clinical Interventions•Electronic data elements

General Infection Control Program Activity

Time spent on IC activities (%)

Proportion of week spent performing IC activities 25

Proportion of week by specific IC activity**

Infection surveillance 31

**Categories are mutually exclusive

Infection Control Committees (ICC) (%)

Facility has an ICC 84

Frequency of ICC meetings**

Monthly meeting 52

Quarterly meeting 38



• 25% of week spent on IC• Nearly one-third of that time

spent on surveillance• Monthly IC meetings

• Assessment of time spent:•Communication•Contact Precautions•Antimicrobial St.•Decolonization•Env. Cleaning•Urinary Catheter Use

•Cluster coaching:

•28% report low time,

staffing as a challenge

• Use of regular ICC meeting

as a resource •13/15 report having an

ICC from MDRO survey•Link to cluster meeting

Infection Surveillance

Data collection (%)

Log book of residents with HAI 76

Record of HAI in electronic database 40

Surveillance (%)

House-wide 80

Targeted for specific infections 56

Tracking infection rates to identify trends 84



• Most facilities perform

surveillance and data

collection• 40% use and electronic

database (excel?)

• Need more stringent

assessment of experience

and comfort with electronic

data collection

•In 8 mo since baseline

•45% of LTC enrolled in

NHSN

•22% report NHSN as

challenge at coaching

• Surveillance discordance

bet. baseline and follow up•2/10 report surveillance

activity (MDRO

Intervention survey)

Infection Control Policy

Development (%) Adherence (%)

Hand hygiene 96 83

Isolation precautions 92 71

Environmental cleaning 96 79

Review antibiotic utilization N/A 58

Restrict use of specific antibiotics N/A 13



• High proportion for hand

hygiene, contact precaution

and env. cleaning• Low proportion for antibiotic

stewardship

• Policy assessment•Decolonization•Surveillance•Urinary Catheter use•Inter facility Comm.

• IP Role: policy vs guidelines

•Collaborative influence on

policy• Increase: Hand hygiene (50%);

Contact precautions (38%);

Environmental cleaning (56%)• Decrease: Antibiotic st. (56%)

• High baseline values

contrast•Challenges – Involvement of

Partners (23%),

Implementation issues (16%)

Staff Training and Resources

(%)

Resources

All staff has computer access 30

QuarterlyMonthly

Annually

IC issue arises

Other

44%

13%

13%

4%

26%

Fre

qu

en

cy o

f T

rain

ing


Survey Missed… Collaborative Missed???

• Training is mostly infrequent• Low proportion has

computer access

• Need assessment of amount

and type of training•Clinical Interventions•Electronic Data

•Training during collaborative• Contact precautions (38%)• Decolonization (31%)• Hand hygiene (44%)• Env. cleaning (44%) • Surveillance (31%)• Urinary catheter use (38%)• Antimicrobial stewardship (44%)

• Collaborative HIT!•Learning sessions•Webinars•General contact

MDRO Management

General MDRO activities (%)

Mechanism to ID residents w/ history of MDROs 82

Performs MRSA surveillance testing at admission 5

Isolation Precautions Policies

Implementation 91

Discontinuation 91

Process for MDRO communication during transfer 82

Strategy for roommate selection 95

MDRO Management

C. difficile specific activities (%)

Contact Precautions

Suspected C.difficile 95

Active C.difficile 100

Active C.difficile infection into private rooms 27

No private rooms

Place with other C. difficile infection residents 73

Place with other residents but use separate commodes/bathrooms

73

Not Applicable 9

Other 5



• Facilities ID patients with

MDRO• Practice policies for isolation• Communicate MDRO

transfer

• Need management

assessment•Decolonization

•Environmental cleaning

•Antibiotic stewardship

•Urinary catheter use

• Anecdotally, little

communication of MDRO at

transfer

• Communication biggest

success of collaborative

• Nothing!

Greatest HAI Challenge

MSRA

C Diff diarrhea

CA-UTI

Other

Influenza

50%

18%14%

14%

5%

Most Challenging Aspect of Infection Control

Environmental Cleaning

Hand Hygiene

InfectionSurveillance

Isolation Precautions

Outbreak ManagementOther

30%

23%

23%

14%5%

5%



• MRSA most challenging• Hand hygiene, isolation

precautions, surveillance

most challenging

• Need assessment of how

time, staffing and resources

challenge IC

• Point prevalence survey: • MRSA 5 fold increase compared

to C Diff

• Anecdotally, env cleaning

more important that shown• Unclear about issues?

• Indirectly dealt with during

1st half of collaborative• More directly assessed

recently with goal setting

and strategy development

Health Department 82

External Sources of Information

Non affiliated hospital infection control personnel 50

External infection control consultant 5

Other (please specify) 9

(%)

American Medical Directors Association 9

Association for Professionals in Infection Control and Epidemiology

32

Centers for Disease Control and Prevention 96

Corporate organization resources 18



• External sources•VDH•APIC•CDC

• VDH result not specific for

role with HAI and MDRO

• Anecdotally, facilities used

to operating independently

• Not quite a miss….what will

be the VDH role in the future

I. Respondent BiasI. 65% response by non – IP may lead

to inconsistent results

II. Not possible to formally compare assessments before and during collaborative

I. Different surveys, respondents, timing

Limitations

I. Collaborative model appears to be

particularly useful for creating sustained effort

II. Baseline survey may be a useful framework

I. Create a more tailored survey for

future collaborative

II. Administered multiple times for more

formal pre/post assessment

Recommendations

HAI TeamDr. Patsy KelsoCarol Wood-Koob Dr. Erica BerlBrant Goode Bradley TompkinsShari Levine VDH staffGerry Thornton

Dr. Nimalie Stone

Dr. Alex Kallen

Dr. John Jernigan

Dr. John Stelling

Herb Lison

Donna Izor

Bill Marcinkowski

Dail Riley

Patty Launer

Monica Boyd

Amanda Masters

Ashlyn Beavor

Dr. Pat McConnan

http://www.who.int/csr/disease/swineflu/en/index.html

multidrug-resistant organism prevention in the long-term care facility setting drugs, bugs and...

Documents

infection preventionist

multifacility chain

basic facility demographics

status of infection

years of ic experience

fte10 years of ic exp

director of nursing

steps measure changes