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

2. 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

3. Presentation Outline History of the project
Description of the collaborative approach
Review of successes and challenges
Focus on the “Burlington Cluster”

4. 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?

5. 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.

6. History (continued) ARRA grant supported:
HAI Prevention Coordinator at VDH
Development of state plan for HAI prevention
NHSN data validation
HAI prevention collaborative

7. Vermont’s Collaborative Vision
For acute and long-term care facilities to work together toward the prevention and elimination of healthcare-associated infections.

8. 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

9. 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.

10. 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

11. Collaborative
Hospitals:
13 in VT
1 in NH

12. Collaborative
LTC Facilities:
40 in VT

13. Patient/Resident Transfers as Reported by Facilities

14. 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

15. 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

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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

24. 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

25. 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

26. 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

27. 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…

28. 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

29. 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

30. 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

31. 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

32. 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