The Vermont Multidrug-Resistant Organism Healthcare-Associated Infection Prevention Collaborative

A Hospital and Long Term Care Facility Partnership: Overview of Our 1st Year Sally Hess, MPH, CIC FAHC, Infection Prevention Manager Carol Wood-Koob RN, CIC HAI Prevention Coordinator Patsy Tassler Kelso, Ph.D State 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. 8 8

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.

What is a Healthcare Cluster? Hospitals and long-term care facilities serving the same community, working together to form a larger team. Hospital (H) Long-Term Care (L) Healthcare Cluster Team (L) (H) (L) (L) 10 10

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 Peer to peer learning and support Geographically Local groups of Acute and Long-term Care Facilities They share patients and Laboratory They are making decisions about what interventions will work for them The Cluster work groups will last beyond the Collaborative

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 Automated data transmission may not happen overnight but we are making strides in the right direction.

MDRO Events from LTC…..using NHSN. Work Flow for LTCF LabID Events MDRO Events from LTC…..using NHSN. A Vision for the Future. Lab data submitted electronically to WHONet by acute care (AC). 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. WHONet Candidate list – excel spreadsheet. AC IP will filter the candidate list; specific to each LTCF in their cluster. AC IP sends candidate list to the LTC IP. FAX, secure file transfer, mail or other agreed upon HIPAA compliant method. LTC IP completes LabID event form for each candidate. Lab ID Event form & Monthly Monitoring forms sent to CDC (need to get specifics from Nimalie on how this could be done). 23

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% enrolled Goal 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 Steps Evaluated current LTC and acute care practices re: isolation & patient placement Reviewed housekeeping practices Created an environmental services checklist Developed an inter-facility communication/transfer form Revised the current FAHC Transition of Care form to include all key elements of the transfer form Reviewed the California enhanced precautions document – recommended changes to the State Developed infection prevention curriculum & presentation for annual LTC staff education

Accomplishments & Next Steps MRSA screening on admission to FAHC CHG bathing on admission to FAHC Successfully transmitted hospital MDRO and C. diff data to NHSN via WHONET Enrollment of LTC facilities in NHSN NHSN MDRO LabID education LTC MDRO and C. diff data to NHSN 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 Branch Centers for Disease Control and Prevention 32