Issues not covered

Employee Health All new employees should have a baseline health assessment, including immunization status TST at time of hire (2-step if indicated) Follow up TST based on risk assessment Immunizations as recommended Influenza HBV, Tetanus (tdap) Managing employee illness and exposure follow-up Hep A in psychiatric and mentally disabled facilities http://epi.publichealth.nc.gov/cd/lhds/manuals/tb/toc.html

Healthcare Personnel Proof of Immunity No State Law requiring Standard of Practice CDC recommends: Influenza annually Measles 2 doses > 28 days apart if no proof of immunity Mumps 2 doses > 28 days apart if no proof of immunity Rubella 1 doses if no proof of immunity Varicella if no proof of immunity Tdap

Employee Health cont’ Published information from governmental organization (i.e., CDC) are available. LTCF are required to prohibit employees with skin lesions or communicable diseases from direct contact with residents and to prohibit employees with potentially infectious skin lesions from contact with residents food.

Healthcare Worker Education Infection prevention education should be provided at the time of employment and regularly thereafter (no less than annually) (Cat IC) Topics should include, but are not limited to: Routes of disease transmission Hand Hygiene Sanitation procedures MDROs Transmission-based precautions OSHA required education

Communicable Disease Reporting State health departments provide a list of reportable diseases (Communicable Disease Report Cards) NC the attending physician is responsible for reporting communicable diseases NC law provides for a designee to do the reporting (i.e., IP or laboratory)

Rules for Licensing Nursing Home - IC Required under NCAC 03H.2209 Rules for Licensing Nursing Home - IC All cases of reportable diseases and outbreaks reported to local health department

NC Communicable Disease Branch phone number: 919-733-3419 NC Subchapter 41A Communicable Disease Control – Section .0100 Confidential Communicable Disease Report NC Communicable Disease Branch phone number: 919-733-3419

ICAR Findings for LTCF Total Number of LTCFs Assessed = 94 44% 55% 39% Domain % Compliant (No gaps) % Non-Compliant (at least 1 gap Major area for improvement IPCP and Infrastructure 44% 55% Policy and Procedure review/update as required Trained IP HCP and Resident Safety 39% 61% TB risk assessment staff and resident Policies for work exclusion Surveillance and Disease Reporting 28% 72% Written OB plan and list of CD Hand Hygiene 9% 91% Monitoring, feedback; preferential use of ABHR Personal Protective Equipment 7 % 93% Monitoring, feedback, training Respiratory Hygiene/Cough Etiquette 26% 74% Signs not posted at entrance; offering facemask to symptomatic persons Antibiotic Stewardship 1% 99% Written policies on prescribing; antibiogram within past 24 months Injection Safety/Point of Care Testing 20% 80% Environmental Cleaning

Hand Hygiene WHO and CDC recommend preferential use of ABHR WHO recommends 20-30 seconds for ABHR and 40-60 secs for entire process if using soap and water CDC recommends “until hands dry” for ABHR and at least 15 seconds for soap and water

MDROs and Isolation

Difficulties with Contact Precautions Lack of private rooms and limited ability to move residents Determining the duration of Contact Precautions Unable to restrict resident mobility and socialization/therapy for long periods Unlikely to document clearance of carriage Large population of residents with unrecognized MDRO carriage

Placement of residents based on risk factors Avoid placing 2 high-risk residents together Safer to cohort low-risk and high-risk residents Don’t change stable room assignments based on culture results unless it poses new risk Long-term Roommates have already shared organisms in the past (even if you just learned about it)

What do the guidelines say? If cohorting is not possible, then placing residents with MDRO with residents who are low risk for acquisition or with anticipated short lengths of stay is advised. While ‘‘low risk for acquisition’’ of an MDRO has not been officially defined, one source suggested that it should include residents who are not immunosuppressed; not on antibiotics; and free of open wounds, drains, and indwelling urinary catheters SHEA/APIC Guideline: Infection prevention and control in the long-term care facility Philip W. Smith, MD, Gail Bennett, RN, MSN, CIC Suzanne Bradley, MD, Paul Drinka, MD, Ebbing Lautenbach, MD, James Marx, RN, MS, CIC, Lona Mody, MD, Lindsay Nicolle, MD and Kurt Stevenson, MD July 2008

Resident characteristics to consider – “the 5 C’s” Cognitive function (understands directions) Cooperative (willing and able to follow directions) Continent (of urine or stool) Contained (secretions, excretions, or wounds) Cleanliness (capacity for personal hygiene) Kellar M. APIC Infection Connection. Fall 2010 ed.

High-risk residents – Contact Precautions during direct care High-risk exposures for MDRO transmission if known carrier and high-risk for acquisition if non-carrier Presence of wounds (fresh/new, multiple, increased stage/size, active drainage) Indwelling devices (IV lines, urinary catheters, tracheostomy, PEG tubes) Incontinence Current antibiotic use Dementia

When to use Contact Precautions and restricted movement Active symptoms of a contagious infection Nausea/vomiting New or worsening diarrhea New or worsening respiratory symptoms New, undiagnosed fever Precautions and restrictions are time limited Infection is ruled out and/or symptoms resolve

When to discontinue Contact Precautions Resume Standard Precautions once high-risk exposures or active symptoms have discontinued Communication to care-givers and clear documentation of rationale is key

10A NCAC 41A .0205 CONTROL MEASURES – TUBERCULOSIS (c)The following persons shall be tested using a two-step skin test method or a single IGRA test, administered in accordance with recommendations and guidelines published by the Centers for Disease Control and Prevention (2) Staff of licensed nursing homes or adult care homes upon employment; (3)Residents upon admission to licensed nursing homes or adult care homes. If the individual is being admitted directly from another hospital, licensed nursing home or adult care home in North Carolina and there is documentation of a two-step skin test or a single IGRA test, the individual does not need to be retested; Annual screening based on risk assessment (done annually). Will post template on web site

(1) If the person has ever had a two-step skin test; or (d) Except as provided in the last sentence of Subparagraph (c)(3) of this Rule, (residents admitted from a healthcare facility) persons listed in Paragraph (c) of this rule shall be required only to have a single TST or IGRA in the following situations: (1) If the person has ever had a two-step skin test; or (2) If the person has had a single skin test within the last twelve months. http://epi.publichealth.nc.gov/cd/lhds/manuals/tb/Chapter_XI_2017.pdf

NC Law The health care organization shall designate one on-site staff member for each noncontiguous facility to direct these activities. The designated staff member in each health care facility shall complete a course in infection control approved by the Department. The Department shall approve a course that addresses: Acute Care SPICE two week course (Part 1 and Part II) Long Term Care SPICE course 2.5 days Outpatient, Dental, Home Health-Hospice Online or in person modules approximately 6 hours long

Influenza Vaccination Both trivalent (three-component) and quadrivalent (four-component) flu vaccines will be available. Trivalent flu vaccines (2 A and 1B) include: Standard-dose trivalent shots (IIV3) that are manufactured using virus grown in eggs. A high-dose trivalent shot, approved for people 65 and older. A recombinant trivalent shot that is egg-free, approved for people 18 years and older. A trivalent flu shot made with adjuvant (an ingredient of a vaccine that helps create a stronger immune response in the patient’s body), approved for people 65 years of age and older (new this season). Quadrivalent flu vaccines (2 A and 2B) include: Quadrivalent flu shots approved for use in different age groups. An intradermal quadrivalent flu shot, which is injected into the skin instead of the muscle and uses a much smaller needle than the regular flu shot. It is approved for people 18 through 64 years of age. A quadrivalent flu shot containing virus grown in cell culture, which is approved for people 4 years of age and older (new this season).   https://www.cdc.gov/flu/healthcareworkers.htm

C diff and HH In conclusion, although soap and water is superior to removing C. difficile spores from hands of volunteers compared to alcohol-based hand hygiene products, there have been no studies in acute care settings that have demonstrated an increase in CDI with alcohol-based hand hygiene products or a decrease in CDI with soap and water. This is why preferential use of soap and water for hand hygiene after caring for a patient with CDI is not recommended in non-outbreak settings. The recommendation to use soap and water preferentially in outbreak settings after caring for a patient with CDI is based on expert opinion as there are no data that demonstrate preferential use of soap and water for hand hygiene after caring for a patient with CDI in an outbreak setting is effective at preventing CDI.

Web Sites of Interest Centers for Disease Control http://www.cdc.gov/ Email Inquiries: cdcinfo@cdc.gov North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) http://www.unc.edu/depts/spice/ NC Department of Health and Human Services, Epidemiology Section http://www.epi.state.nc.us/epi/ Occupational Safety & Health Administration http://www.osha.gov/ NC Division of Environmental Health http://www.deh.enr.state.nc.us/