ACT 52 - Healthcare-Associated Infections Mandatory Reporting Requirements and implications for Long-term Care Facilities Hello, and thank you for joining us. My name is [Author Name]. This presentation addresses [subject]. This presentation is based on an article published in the [Month Year] PA-PSRS Patient Safety Advisory. It is available on the Web site of the Pennsylvania Patient Safety Authority, which is responsible for the Pennsylvania Patient Safety Reporting System or PA-PSRS. All Rights Reserved

HAI Reporting Requirements for Long-term Care Background for Development of the Infection List and Criteria Act 52 requires that nursing homes electronically report patient/resident-specific health care-associated infections (HAIs) to the Patient Safety Authority (known as the Authority) and the Department of Health (known as the Department) using nationally recognized standards based on Centers for Disease Control and Prevention (CDC) definitions. As defined in Act 52, the final list of infections and criteria were developed in consultation with the Department and the Authority’s Health Care-Associated Infection Advisory Panel. The criteria for determining HAIs were developed utilizing the McGeer Criteria together with CDC definitions, which were adapted to the long-term care setting. 1 All Rights Reserved 2

HAI Reporting Requirements for Long-term Care Nursing homes will begin mandatory reporting on April 1, 2009. Nursing homes will report HAIs to both the Authority and the Department through a single web-based interface: the Pennsylvania Patient Safety Reporting System (PA-PSRS). Using a single reporting system eliminates the need for duplicate reporting to both the Authority and the Department. The format for electronic reporting is being established by the Authority in consultation with the Department and the HAI Advisory Panel. This will be addressed in detail during upcoming training programs for nursing homes. Additional requirements are addressed in the final notice which was published on September 20. A copy can be found at www.pabulletin.com 2 All Rights Reserved

HAI Reporting Requirements for Long-term Care Educational Programs Training Training will include opportunities for both in-person and online education relating to the following: Infection list Criteria Format for reporting A series of in-person and electronic training sessions will be held throughout the State between January and March 2009. Nursing homes will be notified of available training opportunities through direct mailings, outreach to industry associations and future public notices. 3 All Rights Reserved

HAI Reporting Requirements for Long-term Care Educational Programs HAI Prevention PSA with assistance of the advisory panel is currently developing educational programs to address HAI prevention for future presentation, utilizing various formats. The quarterly Patient Safety Advisory publication contains educational articles pertaining to Act 52/HAI prevention and in accordance with the Act, these advisories are to be distributed to all staff in nursing homes, including physicians. 4 All Rights Reserved

HAI Reporting Requirements for Long-term Care List of Reportable Infections 1. Symptomatic Urinary Tract Infection 1.1 Indwelling urinary catheter related 1.2 Non-urinary catheter related 2. Respiratory Tract Infection 2.1 Lower Respiratory Tract Infection (Pneumonia/Bronchitis/tracheobronchitis) 2.2 Influenza-like illness 5 All Rights Reserved

HAI Reporting Requirements for Long-term Care 3. Skin and Soft Tissue Infection 3.1 Cellulitis 3.2 Burns 3.3 Vascular and diabetic ulcer (chronic/non healing) 3.4 Device-associated soft tissue/wound infection Tracheostomy site Peripheral/ Central IV catheter site G-tube site Supra pubic catheter site In-dwelling drain In-dwelling vascular catheters (dialysis) 3.5 Decubitus Ulcer (pressure related) 6 All Rights Reserved 7

HAI Reporting Requirements for Long-term Care 4. Gastrointestinal Tract Infection 5. Other infections 5.1 Intra-abdominal infection (peritonitis/deep abscess) 5.2. Meningitis 5.3. Viral Hepatitis 5.4. Osteomyelitis 5.5. Primary Bloodstream Infection 7 All Rights Reserved

HAI Reporting Requirements for Long-term Care Additional Act 52 Requirements for Long-term Care – Impact on Nursing Home Staff Nursing Homes were required to develop an infection control plan within 120 days of the SB 968 effective date (08/19/07). Deadline for submission to DOH was 12/31/07. The plan must include a system to identify and designate patients known to be colonized or infected with MRSA or other MDRO. Procedures to include cultures and screenings for nursing home residents admitted to a hospital. Procedures and protocols for staff who may have been exposed to MRSA or other MDRO. 8 All Rights Reserved

HAI Reporting Requirements for Long-term Care Additional Act 52 Requirements for Long-term Care – Impact on Nursing Home Staff An outreach process for notifying a receiving health care facility of any patient know to be colonized with MRSA or an MDRO A procedure for distribution of advisories from the Patient Safety Authority Best Practice questions Quality Improvement Payments – DOH Benchmarking to begin in 2010 9 All Rights Reserved

HAI Reporting Requirements for Long-term Care References Senate Bill 968 www.pabulletin.com www.psa.state.pa.us PHCA SB 968 - key points for Nursing Homes 10 All Rights Reserved

Antibiotic-resistant Organisms in Long-term care Exponential increase in the incidence of antibiotic-resistant organisms (infections and colonization) in health-care settings Nursing homes are receiving patients from hospitals with multi-drug resistant organisms such as MRSA, VRE and Extended Spectrum Beta Lactamases ( ESBLs). Incidence rates of infections with antibiotic resistant organisms for LTC are variable depending on geographic location, type of resident including age, type of facility, services offered including device associated services etc. 11 All Rights Reserved

Antibiotic-resistant Organisms in Long-term care A year-long study in 2003 in 5 states of newly admitted residents with at least a one-year stay at the facility revealed an incidence rate of 12.7 infections per 1000 residents with considerable variability by state and for specific types of residents regardless of admission diagnosis Risk factors include: Younger residents more likely to develop infection Men at greater risk than women after adjustment for other factors Risk was elevated in residents with diabetes mellitus and PVD, with MRSA being the predominant infection Dialysis patients at high risk for invasive MRSA infection 45.2 cases per 1000 dialysis recipients in 2005 12 All Rights Reserved

Antibiotic-resistant Organisms in Long-term care Indwelling urinary catheters result in the greatest proportion of device-related antibiotic-resistant infections Feeding tubes including nutritional preparations and tube-rinsing solutions IV therapy – strong association with MRSA Multidrug-resistant Organisms (MDROs) Defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents MDROs include MRSA, VRE, enterobacteriaceae such as Proteus, Acinetobacter etc. and Extended Spectrum Beta Lactamases (ESBLs) 13 All Rights Reserved

Methicillin-resistant Staphylococcus aureus MRSA MRSA first identified in the late 1960s By 2003, 59.5% of all Staphylococcus aureus isolates in hospital ICUs were resistant to Methicillin Colonized and infected residents serve as the major reservoir of MRSA in LTC – Point prevalence studies indicate that 23-35% of residents in VA hospitals may become colonized over a period of one to two years Main mode of transmission of MRSA is person to person via hands Environmental surfaces play a limited role in transmission MRSA strain 300-0114 is the predominant strain found in community- acquired skin and soft tissue infections 14 All Rights Reserved

Strategies for prevention of healthcare-associated infections (HAIs) An effective infection control program including a committee and Infection Control designee to oversee the program Policies and Procedures and easy access facility-wide of the IC manual Facility-wide educational programs Effective surveillance programs using standardized criteria to determine infections Outbreak control 15 All Rights Reserved

Strategies for prevention of healthcare-associated infections (HAIs) Communicable disease reporting as per State requirements Effective hand hygiene measures – hand washing and use of alcohol based sanitizers Resident Health programs including influenza and pneumococcal vaccine Employee health programs Antibiotic stewardship and effective monitoring Environmental cleaning programs 16 All Rights Reserved

Strategies for prevention of healthcare-associated infections (HAIs) Appropriate assessment of residents colonized with resistant organisms Appropriate assessment of roommates for placement of colonized residents Case by case assessments Appropriate isolation of colonized/infected residents 17 All Rights Reserved