The Vermont Multidrug-Resistant OrganismHealthcare-Associated Infection Prevention Collaborative

A Hospital and

Long Term Care FacilityPartnership:

Overview of Our 1st Year Sally Hess, MPH, CIC

FAHC, Infection Prevention Manager

Carol Wood-Koob RN, CICHAI Prevention Coordinator

Patsy Tassler Kelso, Ph.DState Epidemiologist for Infectious Disease

Presentation Outline

History of the project Description of the collaborative

approach Review of successes and challenges Focus on the “Burlington Cluster”

Background Healthcare-associated infections (HAIs) are a

significant cause of morbidity and mortality in the US. 1.7 million infections/year 99,000 deaths/year

HAIs are the most common cause of adverse events in healthcare with direct medical costs $35 – 45 billion (adjusted for 2007 inflation).

Impact of infections in long-term care – Unknown?

History ARRA funding provided CDC support for

state health departments in HAI prevention.

VDH, VPQHC, and BISHCA collaborated on Vermont’s proposal. Vermont 1st state to publicly report infection

rates using the National Healthcare Safety Network (NHSN).

Vermont 4th state to report hospital-specific rates.

History (continued)

ARRA grant supported: HAI Prevention Coordinator at VDH Development of state plan for HAI

prevention NHSN data validation HAI prevention collaborative

Vermont’s Collaborative Vision

For acute and long-term care facilities to work together toward the prevention and elimination of healthcare-associated infections.

CDC Called… John Jernigan – your inclusion of long-

term care in HAI prevention is the way to go! Why don’t you Focus on multidrug-resistant organisms

(MDRO) Submit MDRO data electronically to CDC

CDC will provide help from WHONET for electronic reporting from hospital labs.

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What is a MDRO?

Bacteria resistant to certain groups of antibiotics Methicillin-Resistant Staphylococcus aureus (MRSA) Vancomycin-Resistant Enterococcus spp. (VRE) Cephalosporin-Resistant Klebsiella spp.(CephR-

Klebsiella) Carbapenem-Resistant (CRE) Klebsiella spp. Carbapenem-Resistant (CRE) E coli. Multidrug-Resistant (MDR) Acinetobacter spp.

Hospitals and long-term care facilities serving the same community, working together to form a larger team.

What is a Healthcare Cluster?

(H)(L)

(L)

(L)

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Collaborative

Hospitals:

• 13 in VT

• 1 in NH

Collaborative

LTC Facilities:

• 40 in VT

Patient/Resident Transfers as Reported by Facilities

Healthcare Clusters

Geographically local groups of acute and long-term care facilities Share patients and laboratory Group decision-making about what

interventions will work for them Peer to peer learning and support

MDRO Prevention- The CDC Challenge

Innovative interventions to prevent and control MDROs

Communication between facilities Modified contact precautions Environmental cleaning Hand hygiene education, observations Antimicrobial stewardship Chlorhexidine (CHG) use Promoting good urinary catheter

practices

Learning Sessions September 2010 January, May, September 2011 Full-day meetings included:

CDC speakers Vermont subject matter experts NHSN guidance Updates from clusters and facilities

Assessment of Infection Control Programs in LTC - Baseline

A CDC survey was used to assess Infection Control (IC) programs in LTC.

Characteristics of person responsible for IC program: RN’s – 71% (22/31) Certified in Infection Control – 0% (0/31) No specific infection control training – 74%

(23/31) Coordination of infection control

Full time – 10% (3/31) Part time – 90% (28/31)

Cluster & LTC “Coaching”

Phone outreach by VDH and VPQ staff

VDH and VPQ attending cluster meetings

Help with NHSN enrollment Resource material and

educational tools provided for LTCF

Collaborative Successes Enhanced knowledge of infection control

“best practices” Improved communication between facilities

Sharing information, practices, policies & procedures

Inter-facility transfer form

Recognizing environmental services needs Physician involvement in cluster meetings

and discussions about interventions

Collaborative Successes (cont.)

Implementation of enhanced standard precautions

MDRO patient/family educational information

Active surveillance for MRSA Hand hygiene observations Clinical evaluation algorithm for suspected

urinary tract infection (UTI) Training on NHSN enrollment and event

identification

Collaborative Challenges Little control over environmental services Implementing changes in all facilities in a

cluster – not one-size-fits-all Different cultures / approaches to change Lack of engagement of facility

administration Limited personnel resources / time Staff turnover Limited computer skills and access

Reporting MDRO “Events” to NHSN

All 13 VT hospitals enrolled in NHSN ~ 20 LTC enrolled in NHSN WHONET is working with Vermont hospitals to

electronically transmit laboratory & ADT data One of the 1st in the nation to do this! 8 hospitals sending data electronically so far

NHSN is developing a new LTC component Vermont facilities are ahead of the rest of the U.S. In many clusters the hospital IP will report MDRO data

for the long-term care facilities

1. Lab data submitted electronically to WHONet by acute care (AC).

2. WHONet to identify LabID Event candidates for AC and LTCF. Lab data must include a unique identifier for each LTCF i.e.; location code Event candidates identified using NHSN inclusion & exclusion criteria.

3. WHONet Candidate list – excel spreadsheet.

4. AC IP will filter the candidate list; specific to each LTCF in their cluster.

5. AC IP sends candidate list to the LTC IP. FAX, secure file transfer, mail or other agreed upon HIPAA compliant method.

6. LTC IP completes LabID event form for each candidate.

7. Lab ID Event form & Monthly Monitoring forms sent to CDC (need to get specifics from Nimalie on how this could be done).

•Work Flow for LTCF LabID Events

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MDRO Events from LTC…..using

NHSN.A Vision for the Future.

Moving Forward Ongoing cluster meetings

LTCFs that aren’t participating in HAI Collaborative can attend cluster meetings, take advantage of collateral benefits (e.g. transfer form, CHG bathing)

Some clusters already going beyond scope of HAI Collaborative Addressing other organisms Including additional stakeholders (EMTs)

Monthly data transmission to NHSN

Moving Forward (continued) Implementing successful interventions across the

state Additional learning sessions

Subject matter experts (e.g., antibiotic stewardship) Change management skills training

QIO support UVM student projects

RN to BS Program Department of Medical Laboratory and Radiation

Sciences

Residential Care infection prevention training

Infection Preventionists Unite!

VICPA Long-term care IPs invited to join First meeting of larger group in April

2011 Joint VT/NH infection prevention

meeting September 2011

Sharing Vermont’s Successes

CDC Safe Healthcare Blog CDC 2010 HAI Grantee Meeting CDC 50-state conference call 2011 Council of State and Territorial

Epidemiologists Conference Many more to come…

Burlington Cluster

Fletcher Allen Vermont State Hospital Birchwood Terrace Nursing Home Burlington Health and Rehab Center Green Mountain Nursing Center Starr Farm Nursing Center Wake Robin

MDRO Burlington Cluster Goals Identified at the last Vermont Healthcare Infection MDRO Collaborative -

Learning Session #3

Goal 1: Cleaning protocols are followed by housekeeping contractor on transfer and discharge, and daily cleaning

Measure: Surfaces will be audited 2-3 audits per week and protocol will be followed 90% of the time.

To Do: Each facility will review the cleaning protocol for their facility. Need to develop and audit form for each facility

Follow-up: Facilities will provide feedback in a non-punitave way to their contractors

Goal 2: Chittenden cluster will be enrolled in NHSN by the next learning session.

Measure: 100% enrolledGoal 3: Standardize the transfer process to and from acute and long term care. Measure: Audit process for 2 transfers in or out each week completed per

protocol 90% of the time To Do: Standardize transfer form, Finalize and implement workflow transfer

process, develop an audit form. Goal 4: Fletcher Allen Health Care, in collaboration will develop an Infection

Prevention education program for LTC facilities Measure: Customer feedback surveys 90% satisfaction To Do: Presented at least once at each LTC facility before the next learning

session. Develop feedback survey

Accomplishments & Next Steps1. Evaluated current LTC and acute care practices

re: isolation & patient placement2. Reviewed housekeeping practices3. Created an environmental services checklist4. Developed an inter-facility

communication/transfer form5. Revised the current FAHC Transition of Care form

to include all key elements of the transfer form6. Reviewed the California enhanced precautions

document – recommended changes to the State7. Developed infection prevention curriculum &

presentation for annual LTC staff education

Accomplishments & Next Steps

7. MRSA screening on admission to FAHC 8. CHG bathing on admission to FAHC9. Successfully transmitted hospital MDRO and C.

diff data to NHSN via WHONET10. Enrollment of LTC facilities in NHSN11. NHSN MDRO LabID education12. LTC MDRO and C. diff data to NHSN13. LTC infection prevention open forum with Q&A

By demonstrating success as a region,Vermont can serve as a model for MDRO prevention nationally.

John A. Jernigan MD MS (CDC/CCID/NCPDCID)Deputy Chief, Prevention and Response BranchCenters for Disease Control and Prevention