Long-term Care Facility: Surveillance of MDRO and Clostridium difficile Infections

Objectives After this session, the attendee should be able to: Recognize patients with MDRO and/or Clostridium difficile infections (or colonization) Conduct surveillance (track and monitor reports) within the facility Explain the role of data feedback Identify best practices during transfer of a patient to another facility

Self-Assessment Our facility… Yes No Don’t know 1. uses standard definitions (such as McGreer criteria or CDC NHSN definitions) to determine if a resident has an infection 2. reviews provider notes to determine if a resident has an infection 3. maintains a list of residents with healthcare-associated infections in a log book 4. keeps a record of healthcare-associated infections in an electronic spreadsheet or database 5. performs house-wide surveillance of infections among our residents 6. performs targeted surveillance for specific infections among our residents 7. tracks rates of infection over time to identify trends ,e.g., monthly rate, quarterly rate, annual rate 8. creates summary reports (e.g., trends) of healthcare-associated infections 9. reports rates of infections by device days (e.g., # UTIs/1000 urinary catheter days/month) 10. shares infection surveillance data with facility Board members 11. shares infection surveillance data with facility leadership (i.e., CEO, DON, ADON, Medical director) 12. shares infection surveillance data with unit managers 13. shares infection surveillance data with all facility nursing staff 14. shares infection surveillance data with all physicians providing care to residents In your folder, pull out the Self Assessment Form (set I). Please take a few minutes to complete this. So now that you have completed the self-assessment, how many have answered…(please raise your hand) ‘yes’ to all 14 questions? - ‘ yes’ to less than half of the questions? LTC Assessment Tool is found at http://www.cdc.gov/HAI/prevent/prevention_tools.html#ltc

Definition of Infection for Surveillance The following 3 conditions must apply: All symptoms must be new or acutely worse Non-infectious causes of signs and symptoms should always be considered before a diagnosis of infection is made Identification of infection should not be based on a single piece of evidence Identification of infection should not be based on a single piece of evidence – microbiologic and radiologic findings should be used only to confirm clinical evidence of infection. Physician diagnosis should be accompanied by compatible signs and symptoms of infection. Source: APIC, 1996 Source: APIC, 1996

Some Infection Prevention and Control Policies and its Impact on Surveillance Infection surveillance - either ‘whole-house’ (i.e. all residents) or ‘targeted’ toward high risk/high volume… Note disease trends Report data internally – weekly, monthly, quarterly and as needed

McGreer criteria - Set of conditions used to make an empiric diagnosis of a disease syndrome.

Sources of Surveillance Information ?? To determine if a resident/patient has an infection, a nurse/IP have several sources of information: Where do you look? Who do you ask? How do you actually find out if a resident has an infection?

Sources of Surveillance Information Ward rounds / morning report Laboratory results Nurse or physician notes Radiology findings Referring and other HCF in the region Facility transfer forms To determine if a resident/patient has an infection, a nurse/IP have several sources of information: doctor’s notes Nurses’ notes -laboratory results -radiology results To determine what’s going on in/around the community, sources of information include: Information from public health Information from HCF in the region and other referral HCF All the above information are useful in guiding surveillance in the facility

Monthly Infection Log Exercise You will need: McGeer case definitions Monthly infection log Laboratory reports Daily Unit Census

Patient 4 4/3/2012: Mr. Jerry J is admitted to the hospital with pneumonia 4/5/2012: Hospital IP notifies you of the sputum culture result on Mr. Jerry J Modify your Monthly Infection Log to record this information. So, let’s start off with patient number 4, Mr. Jerry J. You see that Mr. Jerry J is part of a little cluster of patients with respiratory disease. On 4/3/2012: Mr. Jerry J is admitted to your local hospital with pneumonia On 4/5/2012: the Hospital IP calls you up and notifies you of the sputum culture result on Mr. Jerry J Look at the lab result for patient # 4 – Mr. Jerry J – and record the result on your monthly infection log. Modify your Monthly Infection Log to record this information.

Patient 4 lab result What is this? (wait for answer) The laboratory has nicely highlighted for you that this is methicillin resistant staphylococcus aureus, so you don’t really have to even think. Record the result on your infection log so that you will have this information for later when we do the monthly summary.

Patient 5 Lab Result Enter the laboratory result for patient # 5. Now we’re on patient 5 on the monthly infection log. What is this laboratory result? Enter this laboratory result on your monthly infection log. Vancomycin-resistant Enterococcus. Notice how this laboratory has very nicely highlighted this result for you. How do you classify the patient according to McGeer? This is a urinary tract infection. Make a note of both of these on your Monthly Tracking Log. Enter the laboratory result for patient # 5. Classify the patient according to McGeer

Case Definition for CDI the presence of diarrhea, defined as passage of 3 or more unformed stools in 24 or fewer consecutive hours; AND a stool test result positive for the presence of toxigenic C. difficile or its toxins or colonoscopic or histopathologic findings demonstrating pseudomembranous colitis. For the next group of patients -- patients 6, 7, 8 and 9 -- you are going to need this case definition. This is the case definition for Clostridium difficile infection. The definition requires the presence of diarrhea --that is, 3 or more unformed stools in 24 hours -- AND a stool test positive for C diff toxin OR pseudomembranous colitis based on colonoscopic or histopathologic findings.

Patient 6 lab result Here is the laboratory result for patient 6. Record the laboratory result for patient # 6 on your monthly infection log. Next, use the CDI case definition to classify patients 6-9. Put the result in the column labeled case status For the purposes of this exercise, you may assume that all patients had 3 or more loose stools in 24 hours. 1. Record the lab result for patient # 6 on the monthly infection log. 2. Classify patients 6-9 according to the CDI definition

Patient 11 Laboratory Result By now, you should be getting the hang of this exercise. Tell me what this laboratory result is, for patient # 11. This is multi-drug resistant Acinetobacter. It can be a real problem in healthcare facilities because of the tendency to contaminate environmental sources, especially sinks or respiratory therapy equipment. It’s a good argument for careful environmental cleaning. MDR Acinetobacter is defined as Acinetobacter that is resistant to 3 or more classes of antibiotics. What classes of antibiotics is this resitant to? Wait for answers: Penicillins Cephalosporins, including 3rd generation cephalosporins Carbapenems Quinolones And, it’s intermediate resistant to some aminoglycosides. This is a bad bug.

Classify Patients 11 and 12 Mr. D (patient 11) has: Fever Hematuria Flank pain Confusion, loss of appetite Mrs. D (patient 12) feels fine Both have the identical organism in their urine. Classify Mr. D and Mrs. D What action should you take? Now, I’m going to ask you to classify Mr. D and Mrs. D. Mr. D has high fever, hematuria, dysuria and he’s not eating. How would you classify him? Me meets the case definition for UTI. Mrs. D does not meet the case definition for UTI. She is colonized. Or, we say she has assymptomatic bacteriuria. Should she be treated? No, she should not be treated. Should she be on the line list? Yes. You want to note that she has acquired the organism, but that she is colonized. As far as action you should take: you should definitely notify the hospital. They should know that Mr. D had a complication after hospitalization. Since he was admitted with CHF, it is possible that he had a foley while he was in the hospital and they need to know he might have a CAUTI.

Patients 11-12 Patient Case Status - McGeer Mr. D UTI Mrs. D (Colonized) Treat: symptomatic UTI Do not treat: asymptomatic bacteriuria ACTION: notify hospital

Patient 13 This is an organism in the Enterobacteriaceae family sensitive to Imipenem. Notice the notation on the laboratory slip. This testing was done by an automated method. The laboratory had not yet implemented the modified Hodge test to determine if the organism was truly carbapenem-resistant. So, this is a possible carbapenem-resistant Enterobacter. Record on your monthly infection log that the organism is a possible CRE.

Patient 14 Here is another example of a CRE. In this case, the organisms is listed as not-susceptible to carbapenem. Notice that the laboratory is not highlighting this result very clearly. They are telling you that the organisms is an extented-spectrum beta-lactamase produced; however, they are not calling the carbapenem resistance to your attention. This is nonetheless a carbapenem-resistant isolate. You should talk to your laboratory and determine if they are tesing for carbapenem resistance and how a positive result for CRE will be reported to you. Ideally, you should be notified by phone of the result. However, a lot of labs are not doing this yet. Note this result as a CRE on your monthly infection log.

PERCENTAGE OF RESIDENTS WITH INFECTION Infection Rate Represents infection during a period of time in relation to a unit of population (percent or per n population) PERCENTAGE OF RESIDENTS WITH INFECTION = # of infection x 100 = Rate of Infection ave. resident census (for the month) = 4 CDI on WEST x 100 = 4% of residents had CDI in April 100 residents (on WEST) Now we are going to talk about infection rates. Infection rates are used to compare rates within facilities and between facilities, and to compare rates over time. One way of calculating a rate is simply to calculate the percentage of patients with an infection. In this example, we are calculating the proportion of residents on the West Unit who developed CDI in April. On average, there are 100 residents on the unit during any given day. There were 4 residents who developed CDI during the month of April. Therefore, 4% of residents had CDI in April.

Resident-days as a Denominator Who records resident-days in your facility? At the same time each day, the total number of residents is recorded. At the end of the month, the total is added up for the month = resident days.

Estimation of Infection Rate INFECTION (INCIDENCE) RATE = Number of xxx infections x 1,000 days Number of resident days in the month Rate of CDI on WEST Unit: = 4 x 1,000 = 1.33 CDI per 1000 resident-days (3000) In this example we will calculate the rate of CDI per 1000 resident days on the West Unit. Again, there were 4 residents who developed CDI in April on the West Unit. There were a total of 3000 resident-days on that unit in April.

Summary of Infection Rates Disease Unit Cases Population Rate per 1000 resident-days CDI West 4 3000 1.33 ALL Influenza North VRE South MRSA

Summary of Infection Rates Disease Unit Cases Population Rate per 1000 resident-days CDI West 4 3000 1.33 ALL 6000 0.67 Influenza North VRE South MRSA

Summary of Infection Rates Disease Unit Cases Population Rate per 1000 resident-days CDI West 4 3000 1.33 ALL 6000 0.67 Influenza North 2000 2 VRE South 1000 0.33 MRSA 1 0.5 0.16

(Demonstrate the excel spreadsheet) Data trends

Questions What action should you take, given these data? When should you take this action?

Questions What action should you take, given these data? Begin control measures Outbreaks should be reported to the LHD When should you take this action? Control measures should be initiated ASAP Outbreaks should be reported immediately

http://www.dhhr.wv.gov/oeps/disease/ob/Pages/default.aspx We’ve worked very hard to try to have tools and guidelines available when you have an outbreak to help you manage the outbreak and bring things under control. Here is our webpage for outbreaks. If you go to this page, and scroll down, you will see a link to outbreak toolkits. On that page, there are toolkits for outbreaks of MDROs, influenza, norovirus… and ….

This is our toolkit for CDI. If you have questions. Call us This is our toolkit for CDI. If you have questions. Call us. We try to be helpful.

Data Feedback Exercise Findings and Conclusions Feedback means sharing the CDI data in the previous graph with important people in your Long Term Care Facility: Housekeeping Medical Director Quality Improvement Committee West nursing staff Data is really important, and we’ve spent most of this session generating data. But now that we’ve generated the data, we need to share it with people so we can get the problem under control. So, we’re going to talk now about how to share this data. First, who are we going to share it with? I’ve listed some people here. Anybody else you would want to share it with? 33

Homework You have friends and partners in this room. If you have MDRO / CDI in your facility, and you transfer to another facility, you can spread the MDRO / CDI in another facility. When you leave here today, evaluate your process for transferring patients to assure that adequate information goes with the patient so the receiving facility knows if Evaluate your patient transfer form to assure notification of facilities when transferring a patient with CDI / MDRO

Found at http://www.cdc.gov/HAI/prevent/prevention_tools.html#ltc

Conclusions We have learned How to get surveillance information How to review laboratory slips and define cases How to record cases systematically How to calculate infection rates How to feed back surveillance data Some ideas for sharing information between facilities Interfacility transfer forms

For Further Information www.dide.wv.gov ‘outbreaks’ Outbreak toolkits ‘healthcare associated infections’ http://www.cdc.gov/hai/ http://www.apic.org/