Strategies for Successful Operationalizing Infection ... LaGrange Single Slides.pdfF880 Infection...

Strategies for Successful Operationalizing Infection Prevention and Control for Today’s Long-Term Care FacilitiesSUSAN LAGRANGE, RN, BSN, NHA, CDONA, FACDONA, CIMT DIRECTOR OF EDUCATION PATHWAY HEALTH

© PATHWAY HEALTH 2017

Objectives Upon completion of this presentation, attendees should be able to:1. Outline the recent industry expectations for Infection Prevention

and Control. 2. Discuss the clinical processes affected by the industry updates.3. List three leadership strategies for successful implementation of an

Infection Prevention and Control Program.

INFECTION Prevention and Control• HAI’s (Healthcare-associated infections)” have been estimated

to account for 1.6-3.8 minion infections and 388,000 deaths annually”

• “Additionally, infections have very high costs to LTC facilities: $38 to $137 million annually for antimicrobial therapy and $673 million to $2 billion for hospitalizations”

https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/implementing -guide.pdf

Change

IINDUSTRY EXPECTATIONS

Readmission Measure and VBP

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http://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.pdf

CMS-State Operations ManualState Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilitieshttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

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Key Areas to Look atUpdated F-Tags potentially associated with Infection ControlF880: Infection ControlF881: Antibiotic Stewardship ProgramF882: Infection PreventionistF883: Influenza and Pneumococcal ImmunizationsF690: Urinary Incontinence (UTI’s)F757: Unnecessary Drugs

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F880 Infection Control“The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:1. “A system for

o preventing, o identifying, o reporting, o investigating, o and controlling infections and communicable diseases for all residents, staff, volunteers,

visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;”

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https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

F880 Infection Control2. “Written standards, policies and procedures to include:

• A system of surveillance designed to identify possible communicable diseases or infections before they can spread

• When and Whom possible incidents of communicable disease or infections should be reported”

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F880 Infection Control(Continued) Policies and Procedures

• “Standard and transmission-based precautionso Type and duration of isolationo The isolation should be least restrictive possible for the resident

under the circumstances• Circumstances when employees are prohibited to work with a

communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease”

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F880 Infection Control(Continued) Policies and Procedures:Hand Hygiene for all staff involved in direct resident contactAntibiotic Stewardship Program (Phase 2-November, 2017)• Protocols• MonitoringA system for recording incidents identified under the facility’s IPCP and corrective action taken

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F880 Infection ControlOther updates to Infection Control• Linens

o Handling, storage, processing and transporting to prevent the spread of infection

• Annual Review: The facility will conduct an annual review of it’s IPCP and update the program as necessary

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F880: Infection ControlNOTE:• Hand hygiene (HH) (e.g., hand washing and/or ABHR): consistent with

accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except when hands are visibly soiled (e.g., blood, body fluids), or after caring for a resident with known or suspected Clostridium (C.) difficile or norovirus infection during an outbreak, or if infection rates of C. difficile infection (CDI) are high; in these circumstances, soap and water should be used”

• Addressing the provision of facemasks for residents with new respiratory symptoms


CMS: F880: Infection Control§483.80(a)(2)(iv)When and how isolation should be used for a resident; including but not limited to: • (A) The type and duration of the isolation, depending

upon the infectious agent or organism involved, and • (B) A requirement that the isolation should be the least

restrictive possible for the resident under the circumstances

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Balance!Keeping residents safe, with quality of care and

isolating in the least restrictive manner for safety

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ANTIBIOTIC STEWARDSHIP

CMS-State Operations ManualAppendix PP-Guidance to Surveyors for Long Term Care FacilitiesF881 §483.80(a) Infection prevention and control program. “The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.”https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

F881: Antibiotic StewardshipINTENT “The intent of this regulation is to ensure that the facility: • Develops and implements protocols to optimize the treatment of infections

by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic;

• Reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; and

• Develops, promotes, and implements a facility-wide system to monitor the use of antibiotics.”


CDC

https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

20http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

CDC

http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

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http://www.ahrq.gov/nhguide/index.html

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AHRQ - Another GREAT RESOURCE

Catheter – Associated UTI’s

CAUTI-Catheter Associated Urinary Tract Infections

AHRQ toolkit• Developed based upon 500 nursing homes across the country• Was a 3-year implementation project• Toolkit is organized in 3 main sections

o Implementationo Sustainabilityo Resources

https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/index.html?utm_source=ahrq&utm_medium=generic&utm_term=&utm_content=2&utm_ campaign=AHRQ_cauti4ltc_2017

LLegionella

The CDC indicates:“Legionnaires’ disease is a serious type of pneumonia caused by bacteria, called Legionella, that live in water. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. Unfortunately, Legionnaires’ disease is on the rise in the United States. To reverse this trend, we are asking for your help to manage the risk of exposure to Legionella from water in your building.” https://www.cdc.gov/legionella/downloads /toolkit.pdf

Legionella Risk

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-30.pdf

Legionella - Continued



https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html


https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html

https://www.cdc.gov/legionella/downloads/toolkit.pdf

RESIDENT IMMUNIZATIONS AND VACCINATIONS

Vaccines - F883Influenza and pneumococcal immunizations• Influenza: The facility must develop P&P’s to ensure that

o Prior to offering the flu vaccine, the resident or representative receives education on the benefits and potential side effects of the vaccine

o Each resident, unless medically contraindicated or if already immunized, is offered the flu vaccine between 10/1 and 3/31 annually

o The resident (or representative) has the opportunity to refuse• Documentation must include the education for the resident (and/or resident

representative) on the benefits and potential side effects, if the resident received or did not and reason why not and administration

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F883: Influenza and Pneumococcal ImmunizationsInfluenza Immunization “The influenza vaccine is given seasonally. The CDC indicates that administering the vaccine when it becomes available each season, rather than date specific, (i.e., “October 1”) is most effective. Facilities should administer the influenza vaccine when it becomes available to the facility. Residents admitted late in the influenza season (typically February or March) should be offered the influenza vaccine as late season outbreaks do occur.”


PPandemic Influenza vs. Seasonal Flu

https://www.cdc.gov/flu/pandemic-resources/basics/about.html

CDC Toolkit - Influenza• Clinical Information• Diagnositc Tests• Antiviral Drugs• Vaccine Recommendations (ACIP)• Institutional Outbreaks and Infection Control• Influenza Activity and Surveillance• Vaccination• Patient Education• Training• Long-Term Care Facilitieshttps://www.cdc.gov/flu/toolkit/long-term-care/index.htm

Vaccines - F883Pneumococcal DiseaseThe facility must develop P&P’s to ensure:• Prior to offering the pneumococcal vaccine, the resident or representative receives

education on the benefits and potential side effects of the vaccine• Each resident will be offered the pneumococcal immunizations unless medically

contraindicated or already immunized• The resident or representative has the right to refuse• Documentation must include the education, if the resident received or did not and

reason why not and administration

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Pneumococcal Vaccines:• 2 Pneumococcal vaccines are licensed in the U.S.:

o PCV13 and o PPSV23

Immunization/Vaccination Program

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CDC’s ACIP Pneumococcal Recommendations

https://www.cdc.gov/mmwr/pdf/wk/mm6434.pdf#page=16

F883: Influenza and Pneumococcal Immunizations

“NOTE: A nursing home may encounter residents who do not have adequate documentation of vaccinations. With the exception of influenza vaccine and pneumococcal polysaccharide vaccine (PPSV), providers should only accept written, dated records as evidence of vaccination. Self-reported doses of influenza vaccine and PPSV are acceptable.”CMS: State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

CLINICAL PROCESSES INDUSTRY UPDATES

Policy and ProceduresPOLICY: It is the policy that this facility’s Infection Prevention and Control Program (IPCP), is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The Infection Prevention and Control Program includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards.

Policies and Procedures!General Infection Control Policy and then Procedures:Examples include:• Accessing Vascular Devices• Annual Review of the Infection Prevention and Control Program• Antibiotic Stewardship• Barber and Beautician Services• Blood and Body Fluid Exposure• Blood and Body Fluid Spill Clean up• Cleaning, Disinfection and Sterilization

Procedures - Continued• Cleaning and Disinfecting Blood Glucose Meters• Cleaning and Disinfecting PT/INR Machine/Monitor• Cleaning and Disinfecting Nebulizer Equipment• Cleaning and Disinfecting Resident Care Equipment• Dishwashing Machine • Finger Stick Devices• Hand Hygiene• Humidifiers• Ice Chests and Machines

Procedures - Continued• Influenza Immunization• Insulin Pens• Linen (Handling, Storing, Processing and Transporting)• Occupational Health• Outbreak Management• Personal Protective Equipment• Pest Control• Pets and Animals in the Long-Term Care Facility• Pneumococcal Immunizations• Point-of-Care Testing

Procedures - Continued• Preadmission Process• Reportable Diseases• Reporting of Communicable Disease• Respiratory Hygiene/Cough Etiquette• Rotating Stock Supplies• Safe Medication Administration• Shelf Life of Sterile Items• Standard Precautions• Sterilization of Critical Devices• Surveillance (Process and Outcome)

Procedures - Continued• System for Recording Infection Prevention and Control Program

Incidents• System for Reporting Surveillance Information to Staff and

Practitioners• Transmission-Based Precautions• Tuberculosis Screening (State Requirements)• Use of Multi-Dose vials• Visitors• AND MORE!

Right from the Beginning!Do you have a comprehensive Preadmission

Screening Process?

It Starts with Preadmission!

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Preadmission AssessmentReview the Medical Record• Diagnosis(es)• Antibiotic Use• Vital Signs• Lab Work (Results or Pending Tests)• ImagingAsk the nursing staff at the hospital (or other entity) about infections or symptoms

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Resident Transfer - CDC Resource

http://www.cdc.gov/hai/pdfs/toolkits/InfectionControlTransferFormExample1.pdf

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Admission Screening Risk FactorsAntibiotic use past 30 daysCurrent symptoms or diagnosisCultures taken and resultsImmunization historyDuration of indwelling catheterPresence of MDROsPrior infection2-step Mantoux - history of positive reactionVaccines**Facilities will be required to incorporate any infection-related care needs on the initial 48 hour baseline care plan

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Criteria for Infection Process for NursesDo your nurses have a process?

Do You Have Tools/Resources?Criteria for Infection Forms• UTI• Skin/Soft Tissue• Respiratory• GI**Evidence of adequate symptomsI.E. Loeb Minimum Criteria, McGeers Criteria

Loeb M, Brazil K, Lohfeld L, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005;331:669Stone, N., Ashraf, M., Calder, J., Crnich, C., Crossley, K., Drinka, P., . . . For the Society for Healthcare Epidemiology Long-Term Care Special Interest Group. (2012). Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeerCriteria. Infection Control and Hospital Epidemiology, 33(10), 965-977. doi:10.1086/66774

LLEADERSHIP STRATEGIES

Leadership Strategies1. Review the following regulatory requirements:F880: Infection ControlF881: Antibiotic Stewardship ProgramF882: Infection PreventionistF883: Influenza and Pneumococcal ImmunizationsF690: Urinary Incontinence (UTI’s)F757: Unnecessary Drugs

Leadership Strategies2. Utilize GOOD tools that will assist you to identify

opportunities to improve your systems for quality and compliance!

• CMS Memo: Ref: S&C 17-09-ALL entitled:Infection Control Pilot: 2017 Updatehttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-09.pdf

Leadership StrategiesThe document identifies:• Infection Prevention and Control

Infrastructure• Infection Preventionist• Quality Assessment and Assurance

Committee• Infection Surveillance• Antibiotic Stewardship Programs• Hand Hygiene• Standard Precautions• Transmission Based Precautions• Injection Practices and Sharps Safety

• Point of Care Devices• Central Venous Line/Catheters• Indwelling Urinary Catheters• Respiratory Therapy• Wound Management• Environmental Cleaning and Disinfection• HealthCare Personnel Safety• Respiratory Disease Prevention• Linen Management• AND so much more!

Leadership Strategies


Leadership StrategiesLTC Survey Pathways from CMS:

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

INFECTION PREVENTION, CONTROL & IMMUNIZATIONCMS-20054

Leadership StrategiesCMS-20054 (5/20/17)

• Hand Hygiene

• PPE

• Transmission-Based Precautions

• Laundry services

• Policies and Procedures

• Infection Surveillance

• Antibiotic Stewardship Program

• Influenza and Pneumococcal Immunizationss

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

Leadership StrategiesCDC - NHSN (National Healthcare Safety Network):

• Tracking

• Education

• Resourceshttps://www.cdc.gov/nhsn/ltc/index.html

Leadership Strategies-CDC-NHSNINFECTION PREVENTION AND CONTROL ASSESSMENT TOOL FOR LONG-TERM

CARE FACILITIES

https://www.cdc.gov/infectioncontrol/pdf/ICAR/LTCF.pdf

Leadership Strategies3. Review State Specific Resources

• Memos related to Infection Prevention and Control• Directives• Reporting of Communicable Diseases Requirements• Contacts for Local/Health Departments

Florida Communicable Disease Reporting

http://www.floridahealth.gov/diseases-and-conditions/disease-reporting-and-management/

Florida Reportable Diseases/Conditions

http://www.floridahealth.gov/diseases-and-conditions/disease-reporting-and-management/_documents/reportable-diseases/_documents/reportable-diseases-list-practitioners.pdf

Leadership Strategies4. Review your current system!

• Policies and Procedures• Forms/Systems• Tracking Process• Surveillance Documentation, Analysis and Reporting• Staff Training• Resident/Visitor training• Documentation

Leadership Strategies5. Make the MOST of the FACILITY ASSESSMENT!

• Risk Assessment• Resources• Equipment• Staffing

o Numberso Typeso Competencies

• Needs for the Program

Leadership Strategies6. Put together a TEAM for Infection Prevention and

Control:• Nursing (Licensed, CNA’s, all shifts)• Dietary• Housekeeping• Laundry• Maintenance• Social Services

Leadership Strategies7. Meet with the Medical Director and the Pharmacy Consultant:

• Regulation Review• Policies and Procedures• How to handle practitioner education• Hospital admissions/transfers• Diagnostic concerns• Etc.

Leadership Strategies8. Plan an all staff educational event!

Leadership Strategies9. Use evidence-based or industry accepted best

practice resources!• Always watch for new updates!

Leadership Strategies10. Understand AND Share your date with the

Interdisciplinary Team!

Leadership Strategies11. Never underestimate the power of solid

communication systems!

Leadership Strategies

12. Audit, Audit, Auditand USE the information for Quality Improvement!

“Well-trained and dedicated employees are the only sustainable source of competitive strength”

-Robert Reich

Questions?

Disclaimer“This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health.”

Sue LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT

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