Multidrug-resistant organism prevention in the long-term care facility setting Drugs, Bugs and Scrubs Vermont Department of Health Matthew Thomas

I.Presentation objective II.Background I.Vermont MDRO Collaborative II.CDC Baseline Survey III.Assessment I.Survey results II.Collaborative results III.Survey limitations IV.Collaborative limitations IV.Overall limitations V.Conclusions and recommendations Presentation Outline

Assess utility of CDC baseline survey in context of Vermont MDRO Collaborative Objective:

I.Presentation objective II.Background I.Vermont MDRO Collaborative II.CDC Baseline Survey III.Assessment I.Survey results II.Collaborative results III.Survey limitations IV.Collaborative limitations IV.Overall limitations V.Conclusions and recommendations Presentation Outline

The Vermont MDRO Collaborative

Cluster Model Acute care hospitals Long term care facilities

Inter-facility transfer form Contact Precautions Hand Hygiene Surveillance Antimicrobial Stewardship Decolonization Environmental Cleaning Urinary Catheterization

Electronic Data Transmission

Collaborative Trainings and Assessments Learning SessionQuarterlyAll day meeting, driven by clinical and data content Action PeriodQuarterlyImplementing interventions Cluster MeetingsVariablePlanning for interventions Cluster Coaching Survey Bi-monthlyAssessment of cluster activity Point Prevalence Survey OnceAssessment of MDRO burden MDRO Intervention Survey OnceAssessment of intervention implementation Unstructured ContactVariableVariable, mainly concentrated on electronic data transmission WebinarVariableDriven by clinical content

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Cluster Coaching Survey Point Prevalence Survey MDRO Intervention Survey Unstructured Contact Cluster Meetings MDRO Collaborative Timeline Sep Action Period Learning Session 2 Learning Session 1 Learning Session 3 Learning Session 4 Baseline Assessment Webinars

1.Evaluate the status of infection prevention and control 2.Understand what is being done to develop implementation strategies and determine next steps 3.Measure changes in practice 4.Determine the extent to which targets are being met 5.Determine the effectiveness of outcomes being achieved Goals of Baseline Assessment Tool

I.Presentation objective II.Background I.Vermont MDRO Collaborative II.CDC Baseline Survey III.Assessment I.Survey results II.Collaborative results III.Survey limitations IV.Collaborative limitations IV.Overall limitations V.Conclusions and recommendations Presentation Outline

Primary Role of Respondent Staff Educator (36%); Director of Nursing (29%); Infection Preventionist (19%)** Average of 3.8 years in that position Type of Facility Long term facility care (94%); Skilled nursing/short term rehab (90%) Average of 105 beds and 91% annual occupancy For-profit institutions (65%)** Independent, free standing (42%); Multi-facility chain (39%)** Basic Facility Demographics **From mutually exclusive categories

Infection Control (IC) Program Personnel No. of years of IC experience, (mean)9.8 No specific infection control training (%)**74 Part time coordination of infection control (%)**90 **Categories are mutually exclusive OneLess than one NoneMore than one 50% 23% 16% 10% Number of FTEs

Survey Says…. Collaborative Says…. Survey Missed…Collaborative Missed… 60% have one or more FTE 10 years of IC experience No specific IC training 90% IC is a part time role Need a clearer distinction between FTE and part time Need an assessment of tech experience, training, access Cluster coaching: 79/108 (73%) to IP Includes both AC and LTC What tasks are reasonable in a low resource setting? Clinical Interventions Electronic data elements

General Infection Control Program Activity Time spent on IC activities(%) Proportion of week spent performing IC activities25 Proportion of week by specific IC activity** Infection surveillance31 **Categories are mutually exclusive Infection Control Committees (ICC)(%) Facility has an ICC84 Frequency of ICC meetings** Monthly meeting52 Quarterly meeting38

Survey Says…. Collaborative Says…. Survey Missed…Collaborative Missed… 25% of week spent on IC Nearly one-third of that time spent on surveillance Monthly IC meetings Assessment of time spent: Communication Contact Precautions Antimicrobial St. Decolonization Env. Cleaning Urinary Catheter Use Cluster coaching: 28% report low time, staffing as a challenge Use of regular ICC meeting as a resource 13/15 report having an ICC from MDRO survey Link to cluster meeting

Infection Surveillance Data collection(%) Log book of residents with HAI76 Record of HAI in electronic database40 Surveillance(%) House-wide80 Targeted for specific infections56 Tracking infection rates to identify trends84

Survey Says…. Collaborative Says…. Survey Missed…Collaborative Missed… Most facilities perform surveillance and data collection 40% use and electronic database (excel?) Need more stringent assessment of experience and comfort with electronic data collection In 8 mo since baseline 45% of LTC enrolled in NHSN 22% report NHSN as challenge at coaching Surveillance discordance bet. baseline and follow up 2/10 report surveillance activity (MDRO Intervention survey)

Infection Control Policy Development (%)Adherence (%) Hand hygiene9683 Isolation precautions9271 Environmental cleaning9679 Review antibiotic utilizationN/A58 Restrict use of specific antibioticsN/A13

Survey Says…. Collaborative Says…. Survey Missed…Collaborative Missed… High proportion for hand hygiene, contact precaution and env. cleaning Low proportion for antibiotic stewardship Policy assessment Decolonization Surveillance Urinary Catheter use Inter facility Comm. IP Role: policy vs guidelines Collaborative influence on policy Increase: Hand hygiene (50%); Contact precautions (38%); Environmental cleaning (56%) Decrease: Antibiotic st. (56%) High baseline values contrast Challenges – Involvement of Partners (23%), Implementation issues (16%)

Staff Training and Resources (%) Resources All staff has computer access30 Quarterly Monthly Annually IC issue arises Other 44% 13% 4% 26% Frequency of Training

Survey Says…. Collaborative Says…. Survey Missed…Collaborative Missed??? Training is mostly infrequent Low proportion has computer access Need assessment of amount and type of training Clinical Interventions Electronic Data Training during collaborative Contact precautions (38%) Decolonization (31%) Hand hygiene (44%) Env. cleaning (44%) Surveillance (31%) Urinary catheter use (38%) Antimicrobial stewardship (44%) Collaborative HIT! Learning sessions Webinars General contact

MDRO Management General MDRO activities(%) Mechanism to ID residents w/ history of MDROs82 Performs MRSA surveillance testing at admission5 Isolation Precautions Policies Implementation91 Discontinuation91 Process for MDRO communication during transfer82 Strategy for roommate selection95

MDRO Management C. difficile specific activities(%) Contact Precautions Suspected C.difficile95 Active C.difficile100 Active C.difficile infection into private rooms27 No private rooms Place with other C. difficile infection residents73 Place with other residents but use separate commodes/bathrooms 73 Not Applicable9 Other5

Survey Says…. Collaborative Says…. Survey Missed…Collaborative Missed??? Facilities ID patients with MDRO Practice policies for isolation Communicate MDRO transfer Need management assessment Decolonization Environmental cleaning Antibiotic stewardship Urinary catheter use Anecdotally, little communication of MDRO at transfer Communication biggest success of collaborative Nothing!

Greatest HAI Challenge MSRA C Diff diarrhea CA-UTI Other Influenza 50% 18% 14% 5%

Most Challenging Aspect of Infection Control Environmental Cleaning Hand Hygiene Infection Surveillance Isolation Precautions Outbreak ManagementOther 30% 23% 14% 5%

Survey Says…. Collaborative Says…. Survey Missed…Collaborative Missed??? MRSA most challenging Hand hygiene, isolation precautions, surveillance most challenging Need assessment of how time, staffing and resources challenge IC Point prevalence survey: MRSA 5 fold increase compared to C Diff Anecdotally, env cleaning more important that shown Unclear about issues? Indirectly dealt with during 1 st half of collaborative More directly assessed recently with goal setting and strategy development

Health Department82 External Sources of Information Non affiliated hospital infection control personnel50 External infection control consultant5 Other (please specify)9 (%) American Medical Directors Association9 Association for Professionals in Infection Control and Epidemiology 32 Centers for Disease Control and Prevention96 Corporate organization resources18

Survey Says…. Collaborative Says…. Survey Missed…Collaborative Missed??? External sources VDH APIC CDC VDH result not specific for role with HAI and MDRO Anecdotally, facilities used to operating independently Not quite a miss….what will be the VDH role in the future

I.Presentation objective II.Background I.Vermont MDRO Collaborative II.CDC Baseline Survey III.Assessment I.Survey results II.Collaborative results III.Survey limitations IV.Collaborative limitations IV.Overall limitations V.Conclusions and recommendations Presentation Outline

I.Respondent Bias I.65% response by non – IP may lead to inconsistent results II.Not possible to formally compare assessments before and during collaborative I.Different surveys, respondents, timing Limitations

I.Presentation objective II.Background I.Vermont MDRO Collaborative II.CDC Baseline Survey III.Assessment I.Survey results II.Collaborative results III.Survey limitations IV.Collaborative limitations IV.Overall limitations V.Conclusions and recommendations Presentation Outline

I.Collaborative model appears to be particularly useful for creating sustained effort II.Baseline survey may be a useful framework I.Create a more tailored survey for future collaborative II.Administered multiple times for more formal pre/post assessment Recommendations

HAI Team Dr. Patsy Kelso Carol Wood-KoobDr. Erica Berl Brant GoodeBradley Tompkins Shari LevineVDH staff Gerry Thornton Dr. Nimalie Stone Dr. Alex Kallen Dr. John Jernigan Dr. John Stelling Herb Lison Donna Izor Bill Marcinkowski Dail Riley Patty Launer Monica Boyd Amanda Masters Ashlyn Beavor Dr. Pat McConnan