multidrug-resistant organism prevention in the long-term care facility setting drugs, bugs and...
TRANSCRIPT
Multidrug-resistant organism prevention in the long-term care facility settingDrugs, Bugs and Scrubs
Vermont Department of Health Matthew Thomas
I. Presentation objective
II. Background I. Vermont MDRO CollaborativeII. CDC Baseline Survey
III. AssessmentI. Survey resultsII. Collaborative resultsIII. Survey limitationsIV. 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 CollaborativeII. CDC Baseline Survey
III. AssessmentI. Survey resultsII. Collaborative resultsIII. Survey limitationsIV. 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 Session Quarterly All day meeting, driven by clinical and data content
Action Period Quarterly Implementing interventions
Cluster Meetings Variable Planning for interventions
Cluster Coaching Survey
Bi-monthly Assessment of cluster activity
Point Prevalence Survey
Once Assessment of MDRO burden
MDRO Intervention Survey
Once Assessment of intervention implementation
Unstructured Contact Variable Variable, mainly concentrated on electronic data transmission
Webinar Variable Driven by clinical content
SepOct
NovDec
JanFeb
MarApr
MayJun
JulAug
Cluster Coaching Survey
Point Prevalence Survey
MDRO Intervention Survey
Unstructured Contact
Cluster Meetings
MDRO Collaborative Timeline
Sep
Action PeriodAction Period 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 CollaborativeII. CDC Baseline Survey
III. AssessmentI. Survey resultsII. Collaborative resultsIII. Survey limitationsIV. 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
One Less than one
NoneMore than one
50%
23%
16%10%
Nu
mb
er
of
FT
Es
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 activities 25
Proportion of week by specific IC activity**
Infection surveillance 31
**Categories are mutually exclusive
Infection Control Committees (ICC) (%)
Facility has an ICC 84
Frequency of ICC meetings**
Monthly meeting 52
Quarterly meeting 38
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 HAI 76
Record of HAI in electronic database 40
Surveillance (%)
House-wide 80
Targeted for specific infections 56
Tracking infection rates to identify trends 84
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 hygiene 96 83
Isolation precautions 92 71
Environmental cleaning 96 79
Review antibiotic utilization N/A 58
Restrict use of specific antibiotics N/A 13
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 access 30
QuarterlyMonthly
Annually
IC issue arises
Other
44%
13%
13%
4%
26%
Fre
qu
en
cy o
f T
rain
ing
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 MDROs 82
Performs MRSA surveillance testing at admission 5
Isolation Precautions Policies
Implementation 91
Discontinuation 91
Process for MDRO communication during transfer 82
Strategy for roommate selection 95
MDRO Management
C. difficile specific activities (%)
Contact Precautions
Suspected C.difficile 95
Active C.difficile 100
Active C.difficile infection into private rooms 27
No private rooms
Place with other C. difficile infection residents 73
Place with other residents but use separate commodes/bathrooms
73
Not Applicable 9
Other 5
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%
14%
5%
Most Challenging Aspect of Infection Control
Environmental Cleaning
Hand Hygiene
InfectionSurveillance
Isolation Precautions
Outbreak ManagementOther
30%
23%
23%
14%5%
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
1st half of collaborative• More directly assessed
recently with goal setting
and strategy development
Health Department 82
External Sources of Information
Non affiliated hospital infection control personnel 50
External infection control consultant 5
Other (please specify) 9
(%)
American Medical Directors Association 9
Association for Professionals in Infection Control and Epidemiology
32
Centers for Disease Control and Prevention 96
Corporate organization resources 18
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 CollaborativeII. CDC Baseline Survey
III. AssessmentI. Survey resultsII. Collaborative resultsIII. Survey limitationsIV. Collaborative limitations
IV.Overall limitations
V. Conclusions and recommendations
Presentation Outline
I. Respondent BiasI. 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 CollaborativeII. CDC Baseline Survey
III. AssessmentI. Survey resultsII. Collaborative resultsIII. Survey limitationsIV. 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 TeamDr. Patsy KelsoCarol Wood-Koob Dr. Erica BerlBrant Goode Bradley TompkinsShari Levine VDH staffGerry 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