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2019 NHSN LTCF Training – CDI and MDRO Surveillance

August 27, 2019

>>Hi, everybody. Can everybody hear me? All right, I’m going to
try to speed through, unless you all want
to skip lunch? Anybody want to skip lunch? Okay, nevermind. All right. So again, my name
is Bola Ogundimu. I’m the infection preventionist
for the long-term care team and I’ll be talking about
the importance of CDI and multi-drug resistant
organism surveillance in our setting. I’m going to skip a lot of this
stuff that’s has already — we’ve already gone over
with the previous speakers. So my presentation objectives
today are multifaceted. So some of the trends in
post-acute care/long-term care, as well as some of
the risks of HAIs and antibiotic resistance we
already talked about earlier. So I’ll be going a little
bit deeper into that, as well as discussing the need
for surveillance activities for MDROs and C. diff and LTCFs. And then I’ll also be
highlighting a few national initiatives to support infection
prevention and control programs and antibiotic stewardship
efforts in our settings. So we already sort of kind of
went over these demographics. As you guys know, our
long-term care setting, particularly nursing home
settings, have changed in terms of the care that we
provide at those settings over the last couple
of years now. Just because I like
to ask questions, I’m going to ask it anyway. So for those of you who work,
I’m assuming, at nursing homes and skilled nursing facilities, is infection prevention your
only job at the facility or is that a rhetorical question? How many people have
two hats that you wear? Quality coordinator, the
educator, DON, ADON, what else? Risk management? Anybody else here? Employee health? Great. So we wear multiple
hats at our facilities. We totally understand and
we empathize with you guys as you try to juggle your
different activities as well as responsibilities
at your facilities. Bottom line is over
time the demographics of our post-acute care
facilities have changed significantly in terms of
the care that we provide at our facilities, as well
as what the expectations are where some of our infrastructure
has not necessarily changed over time. So again, we look at the skilled
nursing facility and some of the publications that
we have, the web links are at the bottom of the slide
so you guys can look it up when you get a chance in
the middle of the training or after the training. But one study that is
particularly important for those of you that are — who’s
from California here? Anybody? Okay, so you
might already know about the Shield Study from
Orange County California that looked at the prevalence of
multi-drug resistance organisms in 21 nursing homes in LTACs in
the Southern California region. So it was a regional
public health collaborative that involved decolonization
of 38 facilities in the Orange County
region based on patient sharing
characteristics of those facilities
in the region. There’s a random sample of about
50 adults in 18 nursing homes and three LTACs, as well
as 17 short-term LTACs, that were screened for a variety of multi-drug resistant
organisms from MRSA, VRE, ESBL to CRE in those facilities. So the study focused on CHG
bathing and the study showed that the prevalence of MDROs
at those facilities was well above 50%, about 70%,
actually 68% in nursing homes and about 80% in long-term care
facilities, LTACs specifically. So the most common MDROs
were MRSA, obviously, that was about 42%, and
then ESBLs were about 34%, and that was in nursing homes. And then in LTACs, the most
common organisms were VRE and ESBL. The study also found that
CRE prevalence was higher in facilities that managed
ventilated LTAC patients or nursing home residents. So again, because I’m curious,
Bola, a Curious George, how many people have
ventilated residents or patients at your facilities? Hand show? Okay, so you see where our care of our residents is
moving over time. The bugs are also
moving with them as well. So it is interesting to look
at the risk change over time in terms of our care as well
as exposure of our residents to different organisms. The study also showed that
the high MDRO prevalence at those facilities highlights
the need for prevention efforts in nursing homes
as well as LTACs, but not only a solo
infection prevention method. There is an advocate for really, I think it was said earlier
regional infection prevention and controls, so that — have you all ever had
folks transferred outside from your facilities? Has anybody never had
folks transferred outside your facilities? Or accepted back
into your facility? So yes, we have folks going
in and out of our facilities. And so what you have at your
Nursing Home A can very easily transfer to your, even your
hospital down the street or your LTAC or rehab center down the street at
any point in time. So there is that need to
have a coordinated effort, involve your public
health, your partners. I think earlier someone
talked about the QIN-QIO — sorry, I call it H-SAG. It’s H-S-A-G, okay. Buffy, sorry. But yeah, so we have our QIN-QIO
partners that can help you in your efforts to outreach
to your neighboring facilities around your very facility. So bottom line, residents
can get transferred at any point in time. You do have to make
sure that you have that infection prevention
control practice within your facility, and
that includes across shifts. Now who has ever worked
night shifts before? Okay, I guess I’m — okay, good. Good. Because I used
to work night shift, so I understand the need to
have that communication process within the facility and
also outside that facility, and to have consistent
practices across the board. So that’s it about
the Shield Study. Another study also, this
is a 2010 study that looked at C. diff infections in
long-term care settings. So in this publication, even
though it’s a little bit less than 10 years ago, C. diff
infections were highlighted and there was a large
number of people shown as entering nursing homes that
were colonized with C. diff. So even if they weren’t
actually sick, they also had that colonization factor
coming into nursing homes. And then the study also showed
like another large number of residents acquire C.
diff while receiving care in nursing homes and highlighted
the need to pay attention to antibiotic use
within facilities, as you guys will probably
hear about the AU module, antibiotic use module, to pay attention while you’re
doing your surveillance to what’s being used to
address those situations with the residents
getting infections. So next up, this particular
study was actually from 2012 and the publication
showed that in the US, there were over 100,000 cases
of C. diff that may be occurring in nursing homes every year. So most of the people with
C. diff infections were shown to have recent exposure
to antibiotics. And almost 80% of them developed
C. diff in the nursing home within the first month
of being discharged from the acute care facility. It also showed almost
one in five residents with C. diff were transferred
back to the hospital because of their infection
and close to 10% died within a month of
their infection. So as we already know, for
those of us that have worked in health care for some
time or even if you haven’t, you probably had your
friends or your family member in health care, so you
realize the exposure that comes with the care that
they may be getting. So we know that there are
multiple healthcare drivers of C. diff infection,
MDROs in healthcare. We also do know that
bacteria can emerge and spread in our healthcare facilities,
and so it becomes easier to identify facilities to
improve bedside practices, which would then
reduce the transmission of these multi-drug
resistant organisms or C. diff during our care of
our residents at our facilities. So Step One, really our
focus, should be our fight against drug-resistant
bacteria, and really it relates to understanding the ways
in which the bacteria that our residents can
get can develop and spread in healthcare facilities,
as well as the community. So I’ll be talking
a little bit more about the other risk factors
that can be associated with the spread of C. difficile, as well as multi-drug
resistant organisms. So again, talked earlier about antibiotic use
driving resistance, and that’s the first risk
factor that I would get into, and it’s not that the drugs
themselves cause resistance automatically, but they create
a situation where strains of bacteria which have
resistance are able to survive because of the susceptible
strains that have been killed off
by taking antibiotics. Some antibiotic exposure
may allow bacteria with existing resistance
to survive or thrive, and then the more we use
such antibiotic agents, the faster the resistance
happens, essentially. So certain resistance
genes are readily shared from one bacteria to another. So this graph in particular
shows that a number of antibiotic prescriptions
increased over time, so we have from 1998
until 2005, again, excuse the little
datedness of this, but this story is
still true even now. So you may notice
that there was a lag from when the prescription
started going up really to when the resistance
was first identified so that once it emerged
in the community, though, it was pretty consistently
increased over time, as you can see from the
curve going up over time, just to show how antibiotic
use increases the capacity for resistance over time. So another risk factor, really,
is the use of medical devices. So if you look back
and see what kind of medical devices we’re
using on our residents, as I had asked earlier, how
many people, show of hands, use or have their
residents on ventilators. We had probably maybe
about six or seven. Can you all raise
your hands up again? Okay, so we have quite
a number of people. How many people use
indwelling urinary catheters on their residents. Okay, how many people
use central lines on their residents? What kind of central lines? Ports? Hopefully not. PICCs? Yes. So mainly PICCs. Any other kind of invasive
devices, just to get a feel? Any trachs? Okay, so we have — how
many people use trachs? Okay. So we’ve got
quite a number of trachs in our audience. So again, we have that resident
exposure to those devices, and over time, as we know,
biofilm is like the slime layer that builds around the
surfaces of those devices, so over time we get
that biofilm build-up. And antibiotics do not
penetrate the biofilm. So what happens, if you
have that resident in and they have their trach for
months, so hopefully not years, what happens over time? The slime builds up, and
then you will inherently get antibiotic resistance from
just the inability to penetrate through the biofilm layer. So again, devices or invasive
medical devices represent another risk factor
to our residents. And that’s just the gunk around
indwelling urinary catheter. I’m not going to go into
colonization versus infection. And one other factor that is
now being talked about even more from multiple studies that we’ve
had over time is really the role of hands of our healthcare
personnel in terms of bacterial contamination
of those hands. So this is another
study from 2003 that was updated a
little bit later. We’ll see the findings
in the next slide, but in the 2003 study, the hands of healthcare workers
was cultured after different resident
care activities and before hand hygiene was
performed in a nursing home, and so personnel would walk
out of the resident’s home, have their hands cultured, and
then they could do hand hygiene. And then the organisms which
grew on these cultures ended up showing gram-negative
bacteria to VRE to staph aureus to yeast. So imagine if that
resident or if that healthcare worker then
went to the next resident and, God-forbid, they
go to a resident with an invasive medical device,
well, then what gets introduced to that next resident,
essentially? So organisms that grew on the hand cultures
were probably likely to be shared love to the
next resident sort of thing. And so this might have us
wondering what the implications of having organism contamination on our hands would be
essentially on our residents. So this same study
group actually ended up having another study 2015,
actually almost 12 years later, that focused on MRSA
transmission or MRSA acquisition
during care of residents. And they looked at different
resident care activities, so it was essentially
looking at interactions of the healthcare
worker with the residents and then going back to
culture to see what kind of residents’ activities were
the highest risk for transfer of the MRSA to the resident. So is anybody surprised by this? Changing linens,
by far, was the — one of the highest risk
activity in terms of taking care of residents, as well
as dressing residents. So the light gray bar represents
contamination of gowns. The darker gray bar represents
contamination of gloves. So we can see really it’s
the trickle-down effect. So the highest contamination,
changing linens, to dressing residents,
to transfer of resident, and going down the stream. Again, you guys can check out
this article in your free time. But the bottom line is the
rate of transmission increased from residents with chronic skin
breakdown, so they were seen as the higher risk or during
higher risk activities from dressing, transferring
residents, providing hygiene, as well as changing
linens, as we saw earlier. And then also, other
activities like morning care or resident bathing, as well as toileting assistance
represented another risk category, although not as high as changing linens was still
a risk in that situation. So again, studies
like these suggest that there are some
risk activities that we are constantly
partaking in in taking care of our residents, and their
needs to be in consideration for how we can decrease the
contamination of our hands as well as our gowns,
gloves and our own clothing. So, speaking more
about risk factors. I think someone talked
earlier about social networks and the spread of MDROs. So this — it’s, well,
it’s almost 10 years now, so 2011 publication was from
an outbreak investigation of KPC producing [inaudible]
CA among patients of acute care and long-term care hospitals,
so we had acute care hospitals and then LTACs in four adjacent
counties in Indiana and Illinois from January 2008
until December 2008. So the study looked
at both traditional and molecular epidemiology
methods and looked at social networks. They did a social
network analysis to see where all these patients or all
these patients were traveling. Essentially they looked at
clinical records for 42 patients and then the patients mostly
had comorbid conditions, so they were probably
likely to get transferred between hospitals as
well as nursing homes and other healthcare settings. And they identified the
different transfer facilities that the patients would go. And if you look at those arrows,
that just showed for like, for instance, your GE
patient went from one facility to the other and you can
really go with the arrow to see where they got transferred
to over that period of time. So again, it just showed that post-acute care facilities
likely amplified the regional burden of multi-drug resistance
with longer length of stay, as well as increasing acuity
of care, and also gaps in infection prevention
programs and practices. So, after seeing
all of that story, why do we need surveillance
anyway? So I always ask myself
this question, and I know this has probably
happened to you guys. This is just the case scenario so you have a 70-year
old Miss Bola admitted from an LTAC to your
nursing home. So she comes in with
a complicated history of back surgery,
prolonged ICU stay, as well as multiple
courses of antibiotics. She spends five weeks in the
LTAC for ventilator weaning, antibiotics and wound care,
and she gets transferred to your nursing home
with a trach, PEG tube, indwelling urinary catheter and partially-healing sacral
pressure ulcer with a wound vac. So what would you guys stay
is the resident’s risk factors for being colonized or acquiring
a multi-drug resistant organism? So we talked about
devices, right? Antibiotic use. What else? Length of stay, right? So she’s pretty much
been — well, I — I’m talking about me now. So I’ve been at multiple
facilities within a relatively short
period of time, right? The other thing is that I also
have some comorbid conditions as well. And I’ve been in surgery
again, prolonged ICU stay. So, guess what? One week later, still
at the nursing home, I become unresponsive
and I’m transferred to the hospital ED
across the street. So I get a fever. I have increased
oxygen requirements, purulent respiratory secretions, and my x-ray shows
a new infiltrate. And that same week, I
suddenly develop diarrhea and the doctor ordered a
stool culture and the culture from my trach shows
the following. So this is the trach secretion with Klebsiella pneumoniae
positive culture, and I do have an infection,
but if we look at that, on the right-hand side, that’s
what my sensitivity looks like. Do you all see that
at your facilities? Has anybody never seen that? Okay, good. Well, not good for me, but
I’m glad that you’ve seen it so you know how you can
identify what’s going on here. So now that I have what I
have, what do you do with me at the end of the day? You’re not alone, and that’s the
point of having this discussion. Now you guys have multiple
resources at your disposal. You have the NHSN training as
well you’ll have the NHSN email, so please email as
much as possible. You will also have your — who’s here from the
state health department? Anybody? Okay, awesome, awesome. You have the state health
— what state are you from?>>Tennessee.>>Tennessee. So we have — what’s
your name, ma’am?>>Vicky.>>So we have Vicky’s number
on speed dial from Tennessee, for those of you from
Tennessee, please contact Vicky, because she is an
enormous resource. And I say that because when I
was at the facility in Georgia and also New York, I had my
health department folks numbers on speed dial and they were
a great collaborative partner for me as I navigated the world of infection control
at my facility. So again, we have
these infection control and assessments and response
activity that CDC funded, the state health
departments, to build capacity for infection prevention and
control at multiple facilities, including nursing
homes, for three years. We have developed that
really strong relationship with our state health
departments and you guys should
definitely tap into it. So try to figure out who
your state health department partners are. We learned a lot about
facilities from this activity, and you can click on the
web link at the bottom if you’re trying to figure out
who to contact for your state so you’re not contacting
Vicky for California. But the other thing is we do
also have the CDC guidance on infection control for
long-term care and that’s on our website, web link for
that is again at the bottom. We also do have our
core elements for antibiotic stewardship
for nursing homes, which is a step-wise — actually
as part of the core elements, -we do have a core
elements checklist and you can download it,
save it, print it out, give it to your medical director
and go through it with him so that you guys can come
up with a plan for setting up an antibiotic stewardship
program at your facility, but don’t feel like you
have to do this alone. So the other thing that we have
is our free CDC nursing home infection prevention
training course. How many people have seen that? Okay, it’s free, you all. So you don’t have to pay,
but you do have to register on CDC Train to get
access to the course. It’s multiple modules
and you don’t have to complete all the
modules at the same time. So if you’re interested
in getting something on transmission based
precautions, for instance, you can click on the
module that’s related to transmission-based
precautions. We encourage people to
go through the modules, but if you’re not able
to find time to go through the entire 23 modules, pick out whatever module
you want to go through. And we have sample policies
as part of the modules that you guys can download
at any point in time. So I know I talk too much, but I will take your
questions at the end. I’ll be back there at
the end, so I’m not going to cut into your lunch. You guys are free to go,
but thank you so much. [ Applause ]

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